Free Discovery Session

Name
Email
1. Is your primary reason for contacting me health related?
2. Is your primary reason for contacting me learning related?
3. What is your age? (Or your child’s age if that is the reason for the session.) Please note if you are referring to someone other than yourself in this questionnaire. (If you are wishing for the Discovery Session to be more learning focused for you or your child, if you like, you can scroll down to #15, however, 4 – 14 may also have an impact on learning.)
4. What would you say your level of health is on a scale of 1 – 10? (Or your child, if that is the reason for the session.)
5. What is your biggest health complaint? (Or your child’s)
6. List all your health complaints.
7. What type of exercise do you partake in? (Or your child)
8. How often do you exercise?
9. How much sugar do you eat daily? (Or your child.)
10. What does your diet look like?
11. What kind of work do you do?
12. What kind of experiences have you had with alternative health?
13. Approximately how many surgeries have you had throughout your life
14. If you were at your optimum level of health, what would you be able to do, that you want to do, that you can’t do now?
15. If you contacted the Kinergist about learning, is it for a child or adult? How old?
16. How far behind is he/she in math, if at all?
17. How far behind in reading, if at all?
18. Would you say you/they were uncoordinated?
19. Can you tell me about the birth and childhood, traumas and when they happened?
20. Any language/speech, handwriting problems?
21. Any behavior problems?
22. In a perfect world, what would you like to see you/this person do that they can’t do now?
23. Please add anything else that would be important for me to know in order for you to get the most out of your complementary session.