Eden Therapies Consultation Form

Eden Therapies Consultation Form
Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
DOB

MonthDayYear
Date
MaleFemalePrefer not to say
GP Details
GP Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
GPConsultantPhysiotherapistChiropractorSports TherpaistMassage TherapistPodiatryOther
If yes, please explain:
Contraindications

Musculoskeletal Problems
StrainsSprainsFracturesMyositisArthritisJoint ReplacementOsteoporosisBursitisTendinitisOther
If yes, please explain:
Circulatory Problems
Heart ComditionHypertensionHypotensionDVTPhlebitisArticles VeinsHaemophiliaCardiovascular DiseaseOther
If yes, please explain:
Neurological Problems
EpilepsySciaticaNeuralgiaMSParkinsonsOther
If yes, please explain:
Skin Problems
EczemaAcneAthletes FootWartsDermatitisPsoriasisImpetigoCutsBruisesBurnsUndisgnosed LumpsOther
If yes, please explain:
Respiratory Problems
AsthmaPneumoniaBronchitisSinitisColdCoughFluOther
If yes, please explain:
Immune Problems
CancerHIVRheumatoid ArthritisAidsOther
If yes, please explain:
Digestive Problems
IBSConstipationDiarrhoeaGall StonesKidney StonesUrinary Tract InfectionOther
If yes, please explain:
Miscellaneous Problems
DiabetesAllergiesRecent operationGlandular feverHeadachesPsychological problemsMenstrual problemsSubstance abuseFeeling unwellOther
If yes, please explain:
If you have checked any of the above boxes please explain:
Medical Health History
Childhood health problemsInherited health problemsOperations/ traumaIllness/ diseaseOther
If you have checked any of the above boxes please explain:
Recent medical history
Areas of painHeadachesFoot/ankle problemsAllergiesDate of last period (if applicable)
Date

MonthDayYear
Date
Medication taken, and what for?
Reason for attending
Lifestyle, habits and emotions
Do you eat a balanced diet?
Do you drink 6-8 glasses of water a day?
Do you have frequent bowel movements?
Do you find it easy to relax?
Do you sleep well (6-8 hours undisturbed a night)?
Do you have a good exercise routine?
Energy rating - 1 being no energy, 10 being full of energy

1

2

3

4

5

6

7

8

9

10

1 is None, 10 is Lots
Stress level rating - 1 being not stressed, 10 being highly stressed

1

2

3

4

5

6

7

8

9

10

1 is , 10 is
Emotional state - 1 being not emotional, 10 being highly emotional

1

2

3

4

5

6

7

8

9

10

1 is , 10 is
Pregnancy
I am over 3 months pregnant. I have discussed the possibility of miscarriage and have been advised by the practitioner that there is no evidence to suggest that having reflexology can provoke a miscarriage and I am willing to go ahead with my treatment at my own risk.
Signature

Clear
I hereby confirm that the information stated above is accurate to the best of my ability. I have not withheld any information which might affect the course of my treatment and agree to receiving reflexology.
Client signature

Clear
Therapist signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Eden Therapies Consultation Form

GP Details

Contraindications

Circulatory Problems

Neurological Problems

Skin Problems

Respiratory Problems

Immune Problems

Digestive Problems

Miscellaneous Problems

Medical Health History

Recent medical history

Lifestyle, habits and emotions

Pregnancy