Maternity Reflexology

Maternity Reflexology

Consultation Form
Personal details

All information given remains strictly confidential. I comply with the General Data Protection Regulation, details of my privacy policy can be viewed on my website at www.kristisloanreflexology.com
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityCounty

Post Code
Phone number*

Area CodePhone Number
Email address
example@example.com
Date of birth*

DayMonthYear
Date
GP details*
Occupation
Ages of any children
Health Information

Caution check - Do any of the following apply to you?*

	Yes	No
Acute undiagnosed pain (refer to GP/A&E)
Allergies
Diabetes
Epilepsy
Osteoporosis
Any heart or blood pressure issues?
Varicose veins/phlebitis in treatment area
Imminent medical tests or procedures
Recent surgery
Injury or condition linked to treatment area
Cancer

If you have answered yes to any of the above, please give details:
Please note that the following are contraindicated conditions: Cellulitis in the treatment area, fever or contagious illness, deep vein thrombosis or pulmonary embolism, or clients that are currently under the influence of alcohol or drugs.
If any of the above contraindications applies to you, please give details:
Medical history
Illnesses, diseases, disorders, accidents, injuries, operations etc.
Current medications and any side effects
Due date/no of weeks pregnant*
Is this a first pregnancy?
If no, please give brief summary of previous pregnancies/births
How has this pregnancy been so far?
Results of any scans/tests
Recent health and lifestyle
Are you experiencing any areas of pain or discomfort?
Overview of general lifestyle
How is your diet?
How much water or other liquids do you drink in a day? e.g. tea, coffee (caffeinated or decaffeinated?)
How is your bowel and urinary health?
Do you smoke or drink alcohol?
How much exercise do you do and what type?
Do you find it easy to relax, and what do you do for relaxation?
How do you feel about your sleep pattern?
How would you rate your energy levels? (1 low, 10 high)
How would you rate your stress levels (1 low, 10 high) and any areas causing stress?
Any other relevant information?
Reason for seeking maternity reflexology?
How did you hear about Kristi Sloan Reflexology?
I am pregnant or trying to conceive. I am aware that there is always a small chance of miscarriage in pregnancy and have been advised by my reflexologist that there is no evidence to suggest that reflexology can cause miscarriage. I am happy to receive treatment.*

Yes
I declare the information in this form to be true, and accept that it is my responsibility to keep my practitioner updated regarding any changes in my health or medication. I am happy to receive reflexology and any other therapies as listed above.
Signature*

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Maternity Reflexology

Personal details

Health Information

Recent health and lifestyle