Consultation Form

Name

First NameLast Name
Date of birth

DayMonthYear
Date
Email*
example@example.com
Address*

Street Address

Street Address Line 2

TownCounty

Post code
Telephone Number*
Mobile or landline
Occupation
GP details*
In case of emergency please give name and number of contact*

Caution check
Medications? *
Acute pain? *
Allergies? *
Diabetes? *
Epilepsy? *
Osteoporosis? *
Heart problems? *
Varicose veins? *
Recent surgery? *
Skin infections? *
If you answered yes to any questions please give details

Contraindications

For Reflexology
Deep vein thrombosis*
Cellulitis *
Pulmonary embolus. *
Fever/illness. *
Recent Medical Health
Any areas of pain currently?
Date of last period if applicable?
How is your diet?
Daily cup intake of tea /coffee?
Daily glass intake of water?
Smoker? Number of cigarettes
Alcohol intake? Units per week
Height*
Weight*
Exercise amount and type.
Can you relax? How do you relax?
Describe your sleep pattern
How is your energy level? (1-10)
What is your stress level? (1-10)
Any other relevant information?
Briefly describe reason for seeking treatment*
I declare the information in this form to be true, and accept that it is my responsibility to keep my practitioner updated regarding any changes in my health or medication. I am happy to receive treatment.
Signature of client*

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Date*

DayMonthYear
Date
For children under 16 years a parental or guardian signature is required.

I request a parent/guardian to remain in the treatment room for children under 16 years.
If applicable this section will be completed at your first session after a discussion with your practitioner.

I am pregnant or trying to get pregnant. I have discussed this with my reflexologist and I understand that while there is a natural chance of miscarriage throughout pregnancy but especially in the first trimester, there is no evidence that reflexology causes miscarriage. I am happy to go ahead with the treatment

Signature:_______________________

Date: __________________
Should be Empty:

Caution check

Contraindications

Recent Medical Health