Client Consultation Form

Personal details

First Name

Last Name

Address Line 1

Address Line 2

City

County

Post Code

Phone no.

Date of Birth

Gender

Height (cm)

Weight (kg)

Occupation

Name and address of your GP:

GP telephone number

Emergency contact name:

Emergency telephone number

Relationship status (other)

Children

Yes

Children and their ages:

Health history

Have you had reflexology before?

Yes

Reason for attending the treatments:

Referred by GP or Private healthcare?

Yes

If yes, please input PHI Number:

Are you experiencing any problems with your feet?

Yes

If yes, please explain:

Are you currently undergoing any other treatments or therapies?

Yes

If yes, please state:

Do you suffer from any allergies?

Yes

If yes, please state:

Are you currently or do you plan to undergo any medical tests?

Yes

If yes, please state:

Have you undergone an operation or will you be undergoing any surgery soon?

Yes

If yes, please state:

Do you take any medication?

Yes

If yes, which medication and what is it for?

Your family history:

Your medical history:

Contraindications

Have you ever or do you suffer from any of the below conditions?
Please tick any of the following which apply

Have you ever or do you suffer from any of the below conditions?

Please tick any of the following which apply

If yes to any of the above, please give details

General wellbeing

Aches and pains

Please tick any that apply and rate out of 10 in terms of pain (10 being the highest).

Back Pain Level

/10

Neck Pain Level

/10

Shoulders Pain Level

/10

Knees Pain Level

/10

Stiff Joints Pain Level

/10

If yes to any of the above, please give details:

Mood
How would you rate your current mood on a scale of 1 to 10 (1 being the lowest mood)?

Mood Level

/10

Textarea

Stress
How would you rate your stress level on a scale of 1 to 10 (1 being the least stressed)

Stress Level

/10

Sleep
How many hours on average do you sleep per night?

Hours of Sleep

Between 1-4

5-8

Do you feel tired during the day?

Yes

Lifestyle

Smoking
Do you or have you ever smoked?

Do you or have you smoked

Yes

How many do you smoke per day or when did you stop?

Alcohol
Do you drink alcohol?

Do you drink alcohol?

Yes

How many units do you drink per week and over how many days?

Exercise
Do you take regular exercise?

Do you take regular exercise?

Yes

What type of exercise do you do?

Diet
How would you rate your diet?

Diet

Poor

Average

Good

Excellent

Are you a vegetarian or a vegan

Yes

Do you drink water regularly?

Yes

Are you pregnant?

Yes

How many months?

Are you currently breastfeeding

Yes

Are there any patterns to your menstrual cycle that you would like to discuss?

Are you currently or have you undergone menopause?

Are you currently breastfeeding

Yes

Is there any other relevant information you would like to add

Client declaration

By signing below, I agree to the following:
I do not suffer from any medical problems other than the ones listed on this form.
I agree to undertake the reflexology treatment(s) and I will seek medical approval from my GP should the situation with my health change.

Signature

Sign Here

Date