Reflexology with Liz Brown

Reflexology with Liz Brown - Health Form
Today's date (should be pre-filled):

DayMonthYear
Date
Name:*

First NameLast Name
Email:*
example@example.com
Address:*

Line 1 address:

Line 2 address:

Village/Town:County:

Postcode:
Mobile or preferred telephone number:*
Age:*
GP name and surgery:*
Emergency contact NAME and TELEPHONE NUMBER:*
Please state your general availability for Reflexology:*
Do any of the following apply, as I may not be able to work on your feet (tick all that apply):

Athlete's foot.First trimester pregnancy.Current cuts/bruises/injuries to the feet or sore skin.Medical oedema.Moderate / advanced varicose veins.Current viral/bacterial illness such as cold, flu, covid, D&V bug, or if you have temperature - (in this case - please reschedule).
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 exercise: *
Please tell me about any diagnosed medical conditions:*
Please tell me about any prescribed medications:*
Please tell me about any previous significant injuries, illnesses or surgeries :*
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 and hydration:*
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?*
--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.

On the day of your treatment I will need you to quickly sign:
- A GDPR (personal data) form.
- A consent to have reflexology form.
- A consultation form to confirm that you've received the treatment.
If you're at all uncertain about 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.

PRIVACY: I will not share your contact information with any third party. I collect health information to work with you safely and effectively. Your information is confidential (my tutor may see an anonymous version whilst I'm in training). Your data is stored securely. Your data is destroyed approximately seven years after the end of our work together. You can request to see any information I hold about you.

By submitting this form you understand the above.

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

Reflexology with Liz Brown - Health Form

--Female only questions--

--End of female only questions--