Information Request Form

Client Info Form

Please be aware that thrombosis, DVT, untreated circulatory issues, cellulitis (to feet or lower leg) and contagious diseases are all contraindications to Reflexology and, as such, a client with any of these will not be treated.
Name

First NameLast Name
Date of Birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Occupation
Address

Street Address

Street Address Line 2

CityCounty

Post Code
Phone Number

Area CodePhone Number
E-mail
example@example.com
GP Address

Street Address

Street Address Line 2

CityCounty

Post Code
Reason for Booking your Treatment:
Any other health information you wish to share?
Please list any medications you are taking:
Do you have any of the following:

Other
If you have ticked any of the above please give details: (Please note Cellulitis in treatment area, fever, DVT, pulmonary embolism, contagious illness or being under the influence of drugs or alcohol are contraindications to treatment)

Lifestyle Info

Rows	Low	Average	High
Stress Level
Quality of Sleep
Quality of Diet (Low=poor)
Amount of Exercise
How would you rate your bowel health?
Energy Levels

Do You Smoke?
How much alcohol do you drink?
Any other Relevant Info:
Pregnancy Declaration
I declare the information in this form to be true, and accept that it is my responsibility to keep my practitioner updated regarding any changes in. Y health or medication. I am happy to receive reflexology and/or Indian Head Massage and any other therapies as discussed with my therapist.
Signature
Should be Empty:

Client Info Form