Reflexology Consultation Form

Hand & Foot Thai Refelexology Massage

Consultation Form

All information is held in strictest confidence. At no given point is information disclosed or shared without client’s written consent.

You may choose to skip answering any question you feel impinges on personal information you do not wish to disclose.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityCounty

Post CodeCountry
Birth Date*

MonthDayYear
Phone Number*
E-mail*
Emergency Contact*
Phone Number*
Occupation
Doctors Name and phone number
Health Information
Medications*
Allergies or sensativities*
Recent hospitalization or injuries*
Are you currently pregnant or breastfeeding?

PregnantWhat Trimester1st2nd3rdComplicationsBreastfeedingOther
Please indicate if any of the following apply to you.

CancerHeadaches/migrainesArthritisDiabetesJoint ReplacementHigh/Low Blood PressureNeuropathyFibromyalgiaStrokeHeart AttackKidney DysfunctionBlood ClotsNumbnessSprains/StrainsArtificial Joint or Pace MakerDigestive ProblemsEating DisorderInflammationStressAnxietyDepressionIrregular Sleep PatternDo you work at a computer?Other

How would you rate... Your Quality of Sleep?

	1	2	3	4	5

1 is Worst, 5 is Best

Your Energy Level?

	1	2	3	4	5

1 is Worst, 5 is Best

Your Stress level?

	1	2	3	4	5

1 is Worst, 5 is Best

Your Quality of Nutrition?

	1	2	3	4	5

1 is Worst, 5 is Best

Your Exercise Habits?

	1	2	3	4	5

1 is Worst, 5 is Best

Treatment Information ~Have you had Thai Massage Reflexology before? ~Why are you seeking Thai Reflexology? ~What are your goals for this session? *

0/200
What Pressure do you prefer?

RelaxingMediumDeepA combination of all 3
Frequency of discomfort- please select the most accurate*

At RestOff/OnConstantWith ActivityWhile WorkingOther
Please indicate areas of discomfort in ~Arms & Hands

RIGHT ForearmLEFT ForearmHand NumbnessNumbness in fingersRIGHT WristLEFT WristSwellingHand SurgeryRIGHT FingersLEFT FingersDiagnosed ArthritisArtificial JointLoss of grip strengthSwollen joints in fingersSore joints in fingersOther
~Legs & Feet

RIGHT CalfLEFT CalfFoot NumbnessNumbness in toesRIGHT ShineLEFT ShineSwellingKnee SurgeryRIGHT KneeLEFT KneeDiagnosed ArthritisArtificial JointRIGHT FootLEFT FootOther
What are your favorite essential oils? (YSY uses doTERRA CPTG)

LavenderLemonPeppermintOrangeGingerTea TreeBergamotGeraniumEucalyptusOther
Client Agreement:

I understand that, Young Spirit Yoga Spa & Studio certified and licensed practitioners do not diagnose illness, disease, any physical or mental disorder, nor do they prescribe medical treatment, pharmaceuticals, or perform joint mobilization.

I acknowledge that holistic therapies are not a substitute for medical examination or diagnosis, and it is recommended that a physician be seen for that service.

It is my choice to receive Thai Massage Reflexology sessions as a form of therapy.

I also understand that at any time I feel pain or discomfort during the session, I will immediately inform althernative therapist so they can adjust the pressure and or treatment.

I have stated my current medical conditions, and will update althernative therapist of any changes in my health status.

By my electronic signature below, I agree to the Thai Massage Reflexology policy and client agreement above.
Please check if you would like to receive information about upcoming special offers at Young Spirit Yoga & Spa

Yes please
Signature*

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Date*

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