Reflexology with Liz Brown

Reflexology with Liz Brown - Health Form
Please note I cannot work on your feet if any of these apply:

Any infection of the feet (such as fungal nails, athlete’s foot, or verrucae). First trimester pregnancy. Any viral / bacterial infection on the day (such as a cold, flu, covid, D&V bug, or if you have a temperature).
Today's date (should be pre-filled):

DayMonthYear
Date
What is your availability for reflexology? (suggested days/times):*
Name:*

First NameLast Name
Date of birth:*
Sex/gender:*
Address*

Street Address

Street Address Line 2

TownCounty

Postcode
Email:*
example@example.com
Mobile or preferred telephone number:*
Emergency contact NAME and TELEPHONE NUMBER:*
GP name and surgery:*
Approximate height and weight:*
Please tell me about any allergies, or please enter N/A:*
What do you do for a living? If retired, please state previous occupation. What is an average day like for you? *
Please tell me about any diagnosed medical conditions:*
Please tell me about anything that you generally struggle or want support with:*
Please tell me about any prescribed medications:*
Please tell me about any previous significant injuries, illnesses or surgeries:*
Please tell me about any exercise: *
Please tell me about your sleep (tick all that apply:*

I sleep well.I have problems falling asleep.I have problems staying asleep.I do not sleep well at all.My sleep is interrupted regularly due to work, family or pets.My sleep varies.
Please put a number to your current general STRESS levels if: 0 = NONE and 10= HIGHEST:*
Please put a number to your current general ENERGY levels if: 0 = NONE and 10= HIGHEST:*
Please tell me about your DIET, HYDRATION and BOWELS:*
Please tick all that apply:

I smoke.I drink more than the recommended units of alcohol regularly (more than 14 units of alcohol a week, or that many units or more over one or two days).I regularly consume daily more than 4 caffeinated drinks (tea/coffee/cola/energy drinks).
What are your aims in having reflexology? You can also tell me about any special needs:*
--Female only questions--

(Please skip to the end if not applicable)
FEMALE ONLY: Menstruation:

Absent.Naturally regular.Naturally irregular.Synthetically controlled.
FEMALE ONLY: Please indicate if you are (please tick all that apply):

Currently trying to conceive.Pregnant.Currently breast feeding.
FEMALE ONLY: Please tell me about any pregnancies or miscarriages (if currently pregnant please state your due date):
FEMALE ONLY: Birth experiences (please select all that apply):

Vaginal delivery.Assisted vaginal delivery (vacuum or forceps).C-section.
FEMALE ONLY: How many children do you have and how old are they?
FEMALE ONLY: Menopause (please select all that apply):

Pre-menopause (I have no symptoms of menopause).Peri-menopause (I have symptoms of menopause).Menopause (I have not had a period for less than 12 months).Post-menopause (I have not had a period for more than 12 months).Surgical or medically-induced menopause.I am taking HRT.
--End of female only questions--
Please use this box if you want to provide any other information or send me a message with your health form:
THANK YOU FOR COMPLETING THIS FORM.

If you're at all uncertain about any aspect of your health, or having reflexology, please speak to your GP.

Reflexology is a complementary therapy and should not be viewed as a substitute for a medical diagnosis or the services of a doctor.

GDPR/Privacy: I collect this information to work with you safely and effectively. I will not share any of your information with anyone, ever. You can request to see any information I hold on you. If I don’t see you for 7 years, I will destroy all information I hold for you.

By submitting this form you understand the above and consent to having reflexology.

PLEASE SCROLL DOWN AND PRESS THE GREEN 'SUBMIT' BUTTON.
Should be Empty:

Reflexology with Liz Brown - Health Form

Please note I cannot work on your feet if any of these apply:

--Female only questions--

--End of female only questions--