Geranium Reflexology Consultation Form

Client Consultation Form

All information is held in the strictest confidence. At no given point is information disclosed or shared without the client’s written consent. You may choose to skip answering any question you feel impinges on personal information you do not wish to disclose.
Name

First NameLast Name
Address*

Street Address

Street Address Line 2

CityCounty

Post CodeCountry
Birth Date

MonthDayYear
Phone Number*
E-mail*
Emergency Contact*
Phone Number*
Occupation
Doctors Name and phone number
Health Information
Medications
Allergies
Recent injuries
Are you currently pregnant or breastfeeding?

PregnantBreastfeeding
Please indicate if any of the following apply to you.

CancerHeadaches/migrainesArthritisDiabetesJoint ReplacementHigh/Low Blood PressureNeuropathyFibromyalgiaStrokeHeart AttackKidney DysfunctionBlood ClotsNumbnessSprains/StrainsDigestive ProblemsDo you work at a computer?StressRegular Sleep PatternAnxietyDepressionInflammation

How do you rate your sleep?

	1	2	3	4	5

1 is Worst, 5 is Best

Stess levels?

	1	2	3	4	5

1 is Worst, 5 is Best

What would you like to achieve from your appointment? E.g. Relaxation or Specific areas of concern*
What Pressure to you prefer?

RelaxingMediumDeepA combination of all 3
Frequency of pain or concern - please select the most accurate*

ConstantOff/OnAt RestWith ActivityOther
Neck

StiffnessPain at neck shoulder junctionPain when turning headPain with side to side movements
Shoulders

Pain in shoulderFrontBackSidePain deep in shoulder jointDiagnosed ArthritisCan't raise arm above shoulder levelCan't raise arm over head
Arms & Hands

Pain in upper armPain in forearmPain in wristPain in fingersSwollen joints in fingersSore joints in fingersDiagnosed arthritisLoss of grip strength
Mid-Back

Mid- back painPain with breathingOther
Low Back

Low back painPinched nerve in low backPain up/down low backPain across low back
Hip

Pain in buttocksPain on side of hipPain deep in hip jointPain on sit boneDiagnosed arthritis
Legs and Feet

Pain down RIGHT legPain down LEFT legLeg crampsNumbness in RIGHT footNumbness in LEFT footNumbness in toesCramps in RIGHT footCramps in LEFT footSwollen LEFT footPain in LEFT FootPain in RIGHT kneePain in LEFT kneeDiagnosed ArthritisOther
What are your favourite aromatherapy oils?

LavenderLemonPeppermintOrangeGingerTea TreeBergamotGeraniumEucalyptus
What is your favourite music option?

Chill out musicSalsaPianoBird songSoulWhale/DolphinPan pipes
Client Agreement:

I understand that Tendai does not diagnose illness, disease, any physical or mental disorder, nor does she prescribe medical treatment, pharmaceuticals, or perform joint mobilization.

I acknowledge that holistic therapies are not a substitute for medical examination or diagnosis, and it is recommended that a physician be seen for that service.

It is my choice to receive reflexology treatments as a form of therapy.

I also understand that at any time I feel pain or discomfort during the session, I will immediately inform Tendai so she can adjust the pressure and or treatment.

I have stated my current medical conditions, and will update Tendai of any changes in my health status.

By my electronic signature below, I agree to the reflexology policy and client agreement above.
Signature*

Clear
Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.
Date*

MonthDayYear
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