Reflexology Form.pdf

The form requires personal and medical information to ensure safe reflexology treatment.

Personal Information:

Name
Email
Phone numbers
Address
Date of birth
Age
Occupation

Medical Information:

Doctor's name and phone number
Last check-up date
Previous reflexology treatments
Current medications
Major illnesses, operations, and allergies
Serious medical conditions

Symptoms and Conditions:

General symptoms (fainting, dizziness, difficulty sleeping, etc.)
Skin conditions (rashes, acne, psoriasis, etc.)
Infections (hepatitis, tuberculosis, HIV/AIDS, etc.)
Respiratory issues (chronic cough, bronchitis, asthma, etc.)
Cardiovascular conditions (high blood pressure, heart attack, etc.)
Gastrointestinal issues (poor appetite, excessive thirst, etc.)
Joint and muscle discomfort (arthritis, bursitis, etc.)

Lifestyle and Health:

Regular exercise and water intake
Sleep habits and eating habits
General health and family medical history

Consent and Signature:

The client attests that the provided information is true and complete.
The client understands that the reflexologist can end treatment at any time due to inappropriate behavior.
The client gives consent to the reflexology session and authorizes the transfer of their health file to another clinic if necessary.
* Signature and date required.