Health History for Reflexology with Susan

Reflexology with Susan Lilley,CR

Confidential Client Health History
Name*

First NameLast Name
Todays Date*

MonthDayYear
Address*

Street Address

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Birth Date*

MonthDayYear
Date
Age
Relationship Status:
Emergency Contact Name:
Medical Information:
Last Medical Visit?*
Medical Findings:
Have you had any accidents?*

YesNo
What/When?
Type a questionDo you have any serious illness?*

YesNo
What/When?
Have you been hospitalized recently?*

YesNo
Why/When?
Have you had any broken bones?*

YesNo
What/When?
Have you had any surgery?*

YesNo
What/When?
Are you on medications?*

YesNo
What/Why? :
Do you have any heart problems?*

YesNo
What/When?
Do you have a pacemaker?*

YesNo
Where/When?
How is your blood pressure?*

Not NormalNormal
Why?
Do you have any circulatory problems?*

YesNo
What?
Are you pregnant?

YesNo
Trimester?
Any history of cancer?*

YesNo
What/When?
Do you have diabetes?*

YesNo
What/When?
Do you have epilepsy?*

YesNo
What/When?
Do you wear any prostheses? (artificial limbs, hearing aids etc)*

YesNo
What/Where?
Do you smoke / Have allergies?*

YesNo
What/When?
Are you taking other therapies?*

YesNo
If yes, List other therapies
Have you had reflexology before?*

YesNo
Who/When?
Who referred you to us?*
What is your Occupation*
Who is your doctor?
Dr Phone Number:
Vax Status*

YesNo
If yes, how many shots?
Specify Brand: Moderna, Pfizer, Novavax, etc.
Present Problems: Reason you would like a treatment.*
Share your story and stay in the loop

Yes! I would love to share my experience, if requested.Please send me Sales, health tips and inspirational emails.
Consent for Reflexology Session with Susan Lilley:

This is to acknowledge my wish to consent to receive reflexology, as outlined to me. I understand that I may withdraw consent at any time and that treatment will then be stopped. Reflexologists DO NOT diagnose, prescribe medication for medical or psychological conditions, or treat for specific conditions.

The information contained on this form is true to the best of my knowledge. I understand and accept that the sessions received are therapeutic value only and fully accept responsibility for the same.
Signature*
Todays Date*

MonthDayYear
Print Name*

First NameLast Name
Please verify that you are human*
Should be Empty:

Reflexology with Susan Lilley,CR

Medical Information: