"The Sole Whisperer", Stacie Peters, RCRT
Reflexology Health Record
Date :______Client’s Name:______
Phone (Res.) ______(Cell)______(Work)______
Address: ______DOB:______
City: ______Province ______Postal Code:______
Email: ______
Would you like to receive, email or text messages for appointments, specials, etc: Yes Or No
1. What is your occupation? ______2.Are you in good health? Yes or No
3. When did you last visit your doctor? ______Reason: ______
______
4. Have you had an Surgeries? Yes or No If YES, please list type and year of surgery: ______
5. Have you had any injuries? Yes or No. If yes, please list what they are and year: ______
6. Are you taking any medications? (Please include any vitamins or dietary supplements) Yes or No
If yes, please list ______
7. Is your blood pressure normal high low stable erratic
8. Are you pregnant? Yes or No If yes, which trimester? 1 2 3
9. Have you had any other pregnancies? Yes or No
10. Do you wear any prostheses? (Example: glasses, contacts, glass eye, artificial limbs/joints, metal plates or wires, dentures, hearing aids.) Yes or No
If yes, please list: ______
"The Sole Whisperer", Stacie Peters, RCRT
Reflexology Health Record
11. Are you presently experiencing any of the following? Yes or No Please circle.
Sunburn Inflammation Pain Headache Skin rash Cold/Flu Cuts/Bruises/Burns , decreased range of motion Other, please list: ______
12. Please indicate your consumption level of the following: Light Moderate Heavy
Salt: Light / Moderate /Heavy Sugar: Light / Moderate /Heavy
Caffeine: Light / Moderate /Heavy Tobacco: Light / Moderate /Heavy
Alcohol : Light / Moderate /Heavy Exercise: Light / Moderate /Heavy
Water: Light / Moderate /Heavy
13. Please indicate which diseases, disorders, and/or conditions you know you have:
Tuberculosis Yes or No HIV/Aids Yes or No
Hepatitis Yes or No Athlete’s Foot Yes or No
Herpes Yes or No Cancer Yes or No
Athlete’s Foot Yes or No Foot Fracture Yes or No
Gangrene of the Foot Yes or No Tendinitis Yes or No
Blisters Yes of No Ulcerations Yes of No
Consent to Receive Treatment
I, the undersigned, consent to reflexology treatment and understand that sessions are for the purpose of stress reduction and relaxation. I may stop the session at any time either during the assessment or the treatment. Reflexologists do not diagnose, prescribe medications for medical or psychological conditions or treat for specific conditions.
Signature: ______Date:______
Thank you for your co-operation and patience!