Reflexology Treatment - Female
Please complete this form as soon as you can, so that I can transfer it to your consultation form prior to your initial session for discussion. This gives me very helpful information about any health conditions or contraindications and reduces our paperwork time on the day so that we can talk in person and so that you can have more hands-on time. Everything answered here is completely confidential beween yourself and me.
Name & address
Date today
(completion of form date)
Date of Birth ../../..
Occupation (for posture/ movement)
Height & Weight
GP Surgery
(I will not be contacting them, this is a legal consulation form requirement).
Lifestyle:
Active
Moderate
Sedentary
Contra-indictions that restrict treatment (select):
Fever
Diarrhoea or Vomiting
Contageous or Infectious Diseases
Recent fractures < 3 months
Localised swelling/ cuts
Skin or Fungal Diseases (eg athlete's foot)
Contra-indications that may require informed consent by you, or medical permission (select):
Asthma
Pregnancy
Epilepsy
Diabetes
Cancer
Arthritis
Osteoporosis
Undiagnosed pain
Acute rheumatism
Cardiovascular issues (BP, heart, varicose veins, clots etc)
Recent operations
Kidney Infections
Slipped Disc
Trapped nerve
Medical Oedema
Neurological condition (PD, MND)
Muscular spasticity conditions
Haemophilia
Nervous / psychotic conditions
Any condition(s) being treated by a GP or complementary therapist
Any details of the above please add briefly here:
~ we can mostly adapt treatments but you may need to sign an informed consent form
PERSONAL PROFILE
This is a little more extensive - tick any areas that apply & detail in box below
SENSITIVIES (current or historical):
ALLERGIES
Hayfever
Dermatitis
Acne
Eczema
Psoriasis
Rosacea
~ provide any detail here.
MUSCULAR / SKELETAL issues:
Back pain
Aches / pain
Stiff Joints
Gout
~ provide any detail here.
DIGESTIVE, URINARY, CIRCULATORY:
IBS
Constipation
Diarrhea
Bloating
Liver/gallbladder
Pancreatic (EPI etc)
Stomach issues
Kidney or urinary
Fluid Retention
Varicose Veins
Other
~ provide any detail here.
NERVOUS SYSTEM / ENDOCRINE
Insulin imbalances
Thyroid condition
Autoimmune condition
Fibromyalgia
Headaches/ Migraine
Stress
Anxiety
Depression
OCD
Other
~ provide any detail here.
IMMUNE SYSTEM:
Prone to infections
Sore Throats
Colds
Chest
Sinuses
Other
~ provide any detail here.
GYNAECOLOGICAL:
PCOS
Irregular or absent periods
Heavy periods
Cystitis
PMS
Perimenopause
Menopause
Endometriosis
Fibroids
Excessive pain
on HRT
on contraceptive pill or implant
Coil fitted
Repeated infections
Other
If you have hormonal conditions or menstruation imbalances to address, please provide as much information as you can here & how it makes you feel - or your main reasons for coming for reflexology treatments.
This will be very helpful.
Date of the first day of last period (if you are in perimenopause or beyond please write that here instead).
Do you track your menstrual cycles / how?
ie, via an app, or temperature monitoring etc
Number of children (if applicable):
Medication taken / Antibiotics / Herbal Remedies / Vitamins
if YES which ones?
Ability to relax - good, medium, poor?
Sleep quaility/ pattern - how is this for you?
Do you spend lots of time using computers?
Do you see natural daylight in your workplace?
Yes / No
Do you eat regular meals / eat on the go / graze / have a tendency towards over/under-eating
Dietary preferences (and habits) ~ Vegan / vegetarian / omnivore / paleo etc. Main protein sources? Lots or little sugar?
How is your daily water intake?
estimate 0 - 0.5L - 1L - 2L - 2.5L
Do you smoke, drink, or take recreational drugs?
If yes, roughly how often?
Do you exercise? None / occasional / irregular / regular / excessive.
If yes, which types?
Current Energy Levels (1-10)
10 is highest
Stress Levels at Work (1-10)
10 is highest
Stress Levels at Home (1-10)
10 is highest
Last question- Have you had reflexology before? (if yes, how long ago).
Please read & acknowledge the points below the box and sign the Informed Consent box, to indicate agreement to receiving full reflexology treatments (or any related holistic massage or reiki therapy if arranged).
Some people experience drowsiness, elimination & healing symptoms after treatments and I understand this is the body's way of rebalancing.
I understand the therapy treatment(s) that I am to receive and I consent to receiving these therapies without my GP's or medical permission, having declared my health conditions. I will tell my therapist during treatment should I feel unwell or wish her to cease treatment. If I have changes to my health conditions I shall update Emma in future sessions.
Pregnancy 1st trimester - Reflexology is contraindicated by some guidelines in this phase, yet there is no evidence to support any harmful effects to mother or baby have occurred. Adaptations are made to avoid reflexes that may effect pregnancy - are you happy to proceed?
Informed Consent:
Submit
Should be Empty: