Reflexology Treatment by Emma

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:
Contra-indictions that restrict treatment (select):
Contra-indications that may require informed consent by you, or medical permission (select):
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):
~ provide any detail here.
MUSCULAR / SKELETAL issues:
~ provide any detail here.
DIGESTIVE, URINARY, CIRCULATORY:
~ provide any detail here.
NERVOUS SYSTEM / ENDOCRINE
~ provide any detail here.
IMMUNE SYSTEM:
~ provide any detail here.
GYNAECOLOGICAL:
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).
Informed Consent:
Should be Empty:

Reflexology Treatment - Female

PERSONAL PROFILE