New Client Medical History Form

CONFIDENTIAL MEDICAL HISTORY FORM

To obtain the best and most effective treatment, I need to know of any medical problems, which may affect your health care.
This form is protected with end‑to‑end encryption, ensuring your information stays completely secure and confidential.
Name*

First NameLast Name
Date of Birth*

DayMonthYear
Occupation*
Gender*
Pronouns
Mobile Number:*
E-mail*
example@example.com
Address*

Address Line 1

Address Line 2

CityPostcode

County
Do you have any accessibility requirements?*

NoYes - please call me on 07349 938602
In case of emergency, please contact:
First Name*
Last Name*
Relationship*
Contact Number*
Where did you hear about me?*

HEALTH INFORMATION*

	Yes	No
Are you attending or receiving treatment from a doctor or specialist?
Do you have any upcoming medical tests?
Are you pregnant or planning to become pregnant?
Do you have or have had any cardio-vascular disorders (e.g. thrombosis, phlebitis, blood pressure, varicose veins, anaemia)?
Do you have or have had any circulation problems (including water retention, cold extremities)
Do you have or have had any peripheral neuropathy (pins and needles) or numbness in your extremities?
Do you have or have had depression, anxiety or panic attacks?
Do you have or have had cancer?
Do you have or have had shingles?
Do you have or have had any surgeries?
Do you have diabetes?
Do you suffer with episodes of fainting, vertigo, blackouts or epilepsy?
Do you have arthritis?
Do you have osteoporosis?
Do you have any infectious diseases or conditions (including athletes' foot)
Do you have any allergies or sensitivities?
Do you have trouble sleeping?
Do you have hormonal problems?
Do you have urinary problems?
Do you have digestive problems?
Do you have any other medical conditions not previously mentions?

Medication & Supplements*

	Yes	No
Are you taking any prescribed medication or supplements? If yes, please list below.

LIFESTYLE INFORMATION*

	Yes	No
Are you exposed to stressful situations, e.g. work, neighbours or family?
Do you exercise regularly?
Do you smoke or vape?
Do you eat a healthy diet?
Do you drink water?
Do you drink caffeinated drinks?
Do you drink alcohol?

If you are having reflexology, it is important to know that it may not be recommended for persons suffering from the following conditions:

Thromobosis, Phlebitis, Gangrene,
unstable heart condition or
any contagious disease.
Client to agree:

All the information I have given on this consultation form is, in all respects, compelte, true and correct to the best of my knowledge. I understand and consent to undergo Reflexology treatments, based on the explanation I have received and the medical information I have provided above.

I shall inform the therapist of any change in my health or medication I am currently taking or shall take in the future.

I agree to the Privacy Policy available on Acorn to Oak Reflexology website
(https://ato-reflexology.com/wp-content/uploads/sites/2615/2025/12/AtO_Reflexology_Privacy_Policy.docx.pdf).
Completed by*
Full Name*

	To be completed on the day of your appointment
Signature
Date

CONFIDENTIAL MEDICAL HISTORY FORM