Reflexology Client Information Form

Baby & Child Reflexology

Consultation Form
Personal details

All information given remains strictly confidential. I comply with the General Data Protection Regulation, details of my privacy policy can be viewed on my website at www.kristisloanreflexology.com
Parental Consent

Before your child's appointment, it would be helpful to fill out and return this intake form and consent. This will enable the best use of the appointment time as well as advising of any issues which may make your child uncomfortable is discussed in front of them.
Name of Child*

First NameLast Name
Name of parent/guardian*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityCounty

Post Code
Phone number*

Area CodePhone Number
Email address
example@example.com
Date of birth*

DayMonthYear
Date
GP details*
Gender
Health Information

Caution check - Do any of the following apply?*

	Yes	No
Acute undiagnosed pain (refer to GP/A&E)
Allergies
Diabetes
Epilepsy
Osteoporosis
Any heart or blood pressure issues?
Varicose veins/phlebitis in treatment area
Imminent medical tests or procedures
Recent surgery
Injury or condition linked to treatment area
Cancer

If you have answered yes to any of the above, please give details:
Please note that the following are contraindicated conditions: Cellulitis in the treatment area, fever or contagious illness, deep vein thrombosis or pulmonary embolism, or clients that are currently under the influence of alcohol or drugs.
If any of the above contraindications applies, please give details:
Medical history
Illnesses, diseases, disorders, accidents, injuries, operations etc.
Current medications/treatments and any side effects
Health and lifestyle
Height & Weight
Siblings - number, ages, brief health
Family - Health or other issues which may be impacting your child
Current stress or anxiety level (1=none, 10=high)
Sleep pattern - Average hours, disturbed/restful
Screen use (phone, tablet, TV, gaming, computer) per day
Diet and Fluids (water, juice etc)
Bowel and urinary health - tummy aches, constipation, diarrhoea
Eye and dental health - Regular check ups
Exercise per week
Any relevant information, conditions, health, emotional state
What are your goals/aims for this first session, reason for seeking Reflexology?
How did you hear about Kristi Sloan Reflexology?
I consent to my child, named above, receiving Reflexology treatment(s) from Rebecca Kristi Sloan Anderson MAR.

To the best of my knowelege, I declare the information in this form to be correct.

I agree to inform Kristi of any changes to my child's health or medication, and if necessary consult a GP before undertaking reflexology treatment.
Signature*

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Baby & Child Reflexology

Personal details

Parental Consent

Health Information

Health and lifestyle