Reflexology Consultation Form

Reflexology Consultation Form

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

DayMonthYear
Date
Name

First NameLast Name
Phone Number

Area CodePhone Number
Address

Address Line 1

Address Line 2
Address

Address Line 3

County
E-mail*
example@example.com
Date of Birth

DayMonthYear
Ages of Children (if any)
Occupation
Doctors Name

First NameLast Name
Next of Kin in case of emergency*
Next of Kin Phone Number

Area CodePhone Number
Health Information
Are you taking any medications
Do you have allergies
Any recent injuries
Are you taking any supplements?
If you answered yes to the above questions, explain further below
Female Question. Are you currently pregnant or breastfeeding?

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

CancerDiabetesHigh/Low Blood PressureCirculatory problemsUnder Active ThyroidOver Active ThyroidKidney DysfunctionHeart Attack/Heart DiseaseStrokeBlood Clots/Thrombosis/Embolism/HaemorrhageBack/neck problemsArthritisInflammationJoint ReplacementNeuropathy/NumbnessFibromyalgiaSprains/StrainsHeadaches/migrainesDepressionAnxietyStressDigestive Problems/IBSDo you work at a computer?Poor Sleep PatternRecent OperationsRecent Injuries
If you have ticked any of the above, please explain further OR if your condition is not listed here please explain further below
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
Do you smoke?

YesNo
How many per day?
Do you drink alcohol?

YesNo
How many times per week?
What is your diet like?

HealthyCould be betterNot good
How much tea and coffee do you drink on a daily basis?
How much plain water do you drink on a daily basis?
Do you exercise? If Yes, then what exercise do you do and how often
How do you relax? i.e. watch TV, read a book, meditate, sleep
How many hours sleep do you get a night undisturbed? If you wake up in the night can you fall asleep again quickly?
Do you wake tired in the morning?
Reason for Visit
What would you like to achieve from your appointment? E.g. Relaxation or Specific areas of concern
If you have a specific concern, when did it first occur? Describe any stress occurring at the time of the onset
Frequency of pain or concern - please select the most accurate

ConstantOff/OnAt RestWith ActivityNot ApplicableOther
Is this condition interfering with

SleepWorkRelationshipsNot Applicable
Please select any areas of pain that may apply to you from the options below
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
Lower Back

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

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
Sign up to Blueberry Holistics newsletter?*

YesNo
Client Agreement
Client Agreement:

I understand that, Caitríona 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 Caitríona so she can adjust the pressure and or treatment.

I have stated my current medical conditions, and will update Caitríona 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*

DayMonthYear
Date
Thank you for providing this information, please be reassured that it will be treated with the greatest confidence, and will only be used in helping you to achieve your goal
Other Comments: Please use this space to give any further relevant information that you feel would be beneficial for me to know prior to your treatment.
Should be Empty:

Health Information

Reason for Visit

Please select any areas of pain that may apply to you from the options below

Client Agreement