Reflexology Consultation Form

Reflexology Consultation Form

All information is held in strictest confidence. At no given point is information disclosed or shared without client’s written consent. You may choose to skip answering any question you feel impinges on personal information you do not wish to disclose.
Date

DayMonthYear
Date
Full Name

First NameLast Name
Date of birth
What is your gender?
Contact Number

Area CodePhone Number
Email Address
example@example.com
Address

Street Address

Street Address Line 2

Town/CityCounty

Postcode
Children, if you have any, and their ages:
Occupation
Check the conditions that apply to you:

AsthmaCancerCardiac diseaseDiabetesHypertensionPsychiatric disorderEpilepsyAnxietyDepressionGastrointenstinal issuesStrokeNeurological conditionMusculoskeletal painHigh blood pressureLow blood pressureCirculatory problemsKidney disfunctionUnder active thyroidOver active thyroidBlood clot/embolism/thrombosis/haemorrhageJoint replacementRheumatoid arthritisOesteoarthritisFibromyalgiaChronic fatigue syndrome/MEHeadaches/migrainesChronic painOther
Please elaborate if you ticked any of the above conditions or have any other health condition not mentioned
Are you pregnant? If so how many weeks?
GP name and address
Next of Kin and contact details in case of emergency
Are you currently taking any medication?

YesNo
Please list them.
Do you have any allergies?

YesNoNot Sure
Please list them.
Do you smoke or vape?
What kind of tobacco products? How long have you used/been using them?
Do you use any kind of illegal drugs or have you ever used them?
What kind of drugs? How long have you used/been using them?
How often do you consume alcohol?

DailyWeeklyMonthlyOccasionallyNever
Are you taking any supplements?
Any recent injuries/operations?
If you answered yes to the above question please give further details
Rate your sleep on a scale of 1 (worst sleep) to 10 (best sleep)
Rate your stress on a scale of 1 (worst) to 10 (best)
What is your diet like?
Do you drink water?
Do you exercise?
How do you relax? Do you apply any relaxation techniques?
What are your hobbies/interests?
Reason for visit: what would you like to achieve from your appointment? E.g. Stress relief, too help a specific physical or mental health condition
If you have a specific concern when did it first start? Describe any stress at the time of onset?
Frequency of pain or concern whether physical or mental

ConstantOn/offAt restWith activityOther
This is interfering with:

SleepWorkRelationshipsNot applicableOther
Please list any areas of pain specifically in the body in list format:
Other Comments: Please use this space to give any further relevant information that you feel would be beneficial for me to know prior to your treatment.
Client Agreement:

I understand that, Lucy does not diagnose illness, disease, any physical or mental disorder, nor does she prescribe medical treatment, pharmaceuticals, or perform joint mobilization.

I acknowledge that holistic therapies are not a substitute for medical examination or diagnosis, and it is recommended that a physician be seen for that service first.

It is my choice to receive reflexology treatments as a form of therapy.

I also understand that at any time I feel pain or discomfort during the session, I will immediately inform Lucy so she can adjust the pressure and or treatment.

I have stated my current medical conditions, and will update Lucy of any changes in my health status.

By my electronic signature below, I agree to the reflexology policy and client agreement above
Signature:
Date:

DayMonthYear
Date
Thank you for providing this information, please be reassured that it will be treated with the greatest confidence, and will only be used in helping you to achieve your goals.
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