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Reflexology

Health History Intake Form

Please fill out this form prior to your first reflexology session:

Today's Date
Date of Birth
Primary Care Physician (Name, Number) if applicable:
Occupation
Do you feel you are in good health?
Are you undergoing other therapies (physical therapy, Mental health therapy, somatics, etc.)?
If yes, please list below...
How often do you exercise?
What are your hopes, curiosities, and questions for our reflexology session?
When did you last visit a doctor?
List past surgeries and their dates...
List past injuries and their dates...
If taking any (even over the counter) medications, please list them below...
If taking any supplements, please list them below...
What (if any) current diagnoses do you have? Please list date of diagnosis and treatment.
Do you sleep well?
Do you suffer from stress / anxiety?
Is your blood pressure...
Are you currently pregnant?
If pregnant, which trimester are you currently in?
Have you had pregnancies in the past?
If pregnant or diagnosed with another present condition, has your doctor approved you for reflexology?
Do you have any allergies or sensitivity to any topical or ingested substances (food, oils, etc.)?
Do you have any varicose veins?
Do you wear any of the following..
Are you currently experiencing...
Please indicate your salt intake:
Please indicate your sugar intake:
Please indicate your tobacco intake:
Please indicate your alcohol intake:
Please indicate your water intake:
Do you have any issues with any of the following systems (check all that apply):
Is there anything else about your health you'd like to discuss?
My acceptance below gives consent for the session and acknowledges that reflexology is not a substitute for medical examination or treatment. It is recommended that I see a physician for any physical ailments that I might have. If I have been diagnosed by a licenced helath professional as having any disease or injury or other physical or mental condition, I understand that I should inform the person who made the diagnosis about the treatment I will be receiving and whether or not I intend to discontinue any treatment or therapy which has been previously ordered, prescribed or reommended by a licensed health professional. I understand that by discontinuing any such treatment or therapy, I assume responsibility for any negative outcome resulting from discontinuing that treatment or therapy.