Consultation Details

Client’s Name:
Address:
Tel No:
Email:
D.O.B: / GP Name:
Clinic Address:
Tel No:
Permission to contact: YES / NO
Occupation:FT / PT
Medical History: (illnesses, diseases, disorders, accidents, injuries, operations etc.)
GP Referral Obtained 
Family Medical History:
Medication: (past and present, duration) / Allergies:
Presenting Conditions: (reasons for Reflexology)

LIFESTYLE

Diet: (typical daily intake, fluids & supplements)
Smoke / Alcohol Consumption:
Hobbies / Relaxation/Exercise:
Stress Levels / Worries and Fears:

SYSTEM REVIEW

Skin: / Skeletal:
Muscular: / Nervous:
Circulatory: / Lymphatic:
Respiratory: / Glandular:
Reproductive: / Renal:
Digestive:
Details of previous Reflexology/other Complementary treatments:

Any Additional Information:

The information used on this consultation sheet is treated with the strictest confidence. Any treatment carried out by is performed with your agreement and at your own risk.
Client Signature:Date:
Reflexologist’s Signature:Date:

Contra-Indications

In order for me to carry out the safest and most beneficial treatment for you, it is necessary to ask the following questions. Please tick either no or yes where necessary:

Do you have or are currently affected by any of the following conditions:

No Yes

Any form of infection, disease or fever  

Diarrhoea or vomiting  

For women - are you in the first 3 months of pregnancy  

No Yes No Yes

Diabetes  Asthma  

High blood pressure  Trapped/pinched nerve  

Low blood pressure  Epilepsy  

Heart conditions  Nervous system dysfunction  

Blood conditions  Whiplash  

Cancer  Acute rheumatism  

Osteoporosis  Arthritis  

Undiagnosed pain   Recent operations  

Any other diagnosed condition being treated by a GP or other complimentary practitioner?

______

______

Disclaimer

For my records, I need to confirm that you have read, understood and answered all of the previous questions. If there is anything you do not understand, please ask me. Otherwise, please read the following and sign below:

To the best of my knowledge, the information I have given is true and I have not withheld any information concerning my health. I will keep Jo updated on my health, should there be any changes to the answers given above. I understand that there is a possibility that I may experience some minor reactions as my body adjusts to the treatment.

I understand that a Reflexologist does not diagnose illness, disease or any other physical or mental condition. I understand that this treatment is not a substitute for medical examination, diagnosis or treatment. While I recognise that all due care will be taken by the therapist, I am aware that my participation in the treatment is voluntary.

Signed:

Client ______Date ______