Billericay Reflexology - Medical History
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address 2
Town
County
Post code
What is your Gender?
*
Male
Female
Other
Check the conditions that apply to you:
*
Asthma
Cancer
Cardiac disease
Diabetes
Hypertension
Psychiatric disorder
Epilepsy
None
Other
Check the symptoms that you have experienced in the past 12 weeks
*
Fever/Chills
Unexplained change in weight
Fatigue/Malaise/Generalized weakness
Headaches/Migraines
Dizziness
Sinus Pain/Pressure/Discharge
Excessive snoring
Wheezing/Chronic Cough
Shortness of breath
Chest pain, pressure or tightness
Swelling of hands/feet/ankles
Nausea/Vomiting
Abdominal pain
Heartburn
Constipation or diarrhea
Stiffness/Pain in joints/muscles
Joint swelling
Bleeding/Easy bruising
Excessive urination
Excessive thirst/hunger
Hot flashes
Painful/Bloody urination
Difficulty urinating/Night-time urination
Urinary incontinence (leakage)
Sexual Difficulties/Painful intercourse
Rash/Skin Conditions
Anxiety/Panic Attacks
Concentration Difficulty
Feelings of Guilt
Insomnia/Problems with Sleep
Loss of energy
None
Other
Date of last menstrual period
-
Month
-
Day
Year
Date Picker Icon
Do you have irregular or painful periods?
Yes
No
Not Applicable
Are you currently pregnant?
*
Yes
No
Trying to conceive
Not Applicable
If yes, please state now many weeks gestation you will be at the time of your appointment
Number of previous pregnancies
Number of children
Are you taking any hormones or birth control?
Yes
No
Are you currently taking any medication?
*
Yes
No
If so, please list:
Do you have any allergies?
*
Yes
No
If so, please list:
Do you use or do you have history of smoking?
*
Please Select
Yes
No
How often do you consume alcohol?
*
Daily
Weekly
Monthly
Occasionally
Never
Which best described your skin type (you can select multiple)
Normal
Dry
Oily
Combination
Young
Mature
How healthy do you feel in general?
Date of Appointment
*
-
Month
-
Day
Year
Date Picker Icon
Signature
*
Submit
Print Form
Should be Empty: