Client Information Form

About You

First Name *

Surname *

Date of Treatment *

Date of Birth *

Telephone *

Address line 1 *

Address line 2

County *

Postcode *

Email *

Number of Children *

Occupation *

Health Information

GP Details *

Health Information *

Medications *

Caution Check

Acute undiagnosed pain (refer to GP/A&E) *

Allergies *

Diabetes *

Epilepsy *

Osteoporosis *

Low or high blood pressure ? *

Varicose veins/phlebitis in treatment areas? *

Imminent medical tests or procedures? *

Recent Surgery? *

Injury or condition linked to area worked? *

If you've answered yes to any of the above please give details

Note on Contraindications

Please note that the following are contraindicated conditions: Cellulitis where you are working over the area, fever or contagious illness, deep vein thrombosis or pulmonary embolism, or clients that are currently under the influence of alcohol or drugs.

Recent Medical Health

Do you have any areas of pain at the moment? *

Date of your last period/ how are your periods (if applicable) *

Lifestyle

How is your diet? *

What do you drink in a day? eg, water, tea, coffee *

Bowel and urinary health *

Smoking/Alcohol *

Do you exercise? *

Do you find it easy to relax and how do you relax? *

Describe your sleep pattern *

How would you rate your energy levels? *

How would you rate your stress levels? *

Any other relevant information?

Reason for seeking reflexology *

Is the therapist offering any other therapies this session, if so what? *

Please note * I am pregnant or trying to get pregnant. I have discussed this with my reflexologist and I understand that while there is a natural chance of miscarriage throughout pregnancy but especially in the first trimester, there is no evidence that reflexology causes miscarriage. I am happy to go ahead with the treatment.

I accept

Declaration * 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.

I accept

Lisa Hodgkinson | Reflexology Culbokie | Reflexology Highlands

lisa@lisahodgkinson.co.uk