Client Consultation FormPlease enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Phone Number *Date of birth *Emergency Contact Details *Phone Number *GP details and surgery *Preferred therapy - Reflexology, Reiki or Indian Head Massage, and reason for seeking this therapy *Diagnosed Medical Conditions or recent health issuesMedicationAny Areas of PainDigestive IssuesDiet Selected Value: 00 - Not so good. 10 - Very goodExercise Selected Value: 00 - Not so good. 10 - Very goodSleep Pattern Selected Value: 00 - Not so good. 10 - Very goodEnergy Levels Selected Value: 00 - Not so good. 10 - Very goodStress Levels Selected Value: 00 - Low. 10 - HighCaution checkAcute painAllergiesDiabetesEpilepsyOsteoporosisCardiovascular conditionVaricose veins/phlebitisImminent medical tests or proceduresRecent surgeryInjury to the feet or foot conditionThe above are contraindicated conditions: severe athletes foot, fever or contagious illness, DVT or pulmonary embolism, cellulitis, clients under the influence of drugs/alcohol. Clients with heart conditions and high or low blood pressure can be treated if the symptoms are under control by medication. Please tick any that apply to you.If you have selected any of the above, please give details below, or on separate sheet. Or if there are any other concerns or information you would like to give, please do so here or on separate sheet.Is anyone in your family, in your bubble or that you have recently seen had any symptoms of Covid-19? *NoYesIs anyone in your family or in your bubble considered extremely vulnerable or are they shielding? *NoYesBy undertaking this treatment do you understand that every precaution has been taken to keep the treatment and the premises as safe as possible, and should you catch Covid-19, it is not the responsibility of your reflexologist? *AgreeI am pregnant or trying to get pregnant. I have discussed the possibility of miscarriage and have been advised by the practitioner that there is no evidence to suggest that having reflexology can provoke a miscarriage, and I am willing to go ahead with the treatment at my own risk. *YesN/AI declare this information to be true and will advise my practitioner of any changes in my health or medication. I am happy to receive reflexology. *AgreeSubmit
