Reflexology Consultation Form

Full name

Email address

Profession (inc. if full time/part time)

GP Address

Lifestyle

Active

Sedentary

Both

Birthday

Month

Day

Year

No of children (if applicable)

Date of last period (if applicable)

Contraindications

Contraindications that require medical permsion

Please provide relevant further details re boxes ticked above, or details of any diagnosed medical condition not listed above:

Contraindications that restrict treatment

Please indicate if you are experiencing any of the below:

Health History

Please list any muscular / skeletal problems (e.g. stiff joints, headaches, back pain)

Please list any digestive system concerns (e.g. constipation, bloating, stomach pain)

Please list any circulation-related symptoms (e.g. fluid retention, tired legs, varicose veins (anywhere on body), kidney problems, cold hands/feet)

Please list any gynaecological concerns or info (e.g. irregular periods, PMT, PMDD, menopause, taking HRT/pill, coil etc.)

Please list any nervous system concerns (migraines, tension, stress, depression)

Please list any immune system concerns (e.g. prone to infections, sore throats, colds, sinusitis)

Please list regular medication (inc antibiotics) taken

Please list herbal remedies taken

Lifestyle Information

How would you describe your current ability to relax?

Good

Average

Poor

How would you describe your sleep at the moment?

Good

Average

Poor

Do you use screens regularly (for work and/or pleasure)? If so, how many hours per day?

Do you take any food or vitamin supplements? (If yes, please list)

Do you eat in a hurry, or does stress impact your eating habits?

How many glasses of water do you drink per day?

Please detail any restricted food groups

Do you smoke? (If so, how many per day?)

Do you exercise:

Never

Occasionally

Irregularly

Regularly

What type of exercise do you do (if applicable)?

Is your skin allergic to anything? If so, please detail

At WORK stress levels (ignore if not working)

At HOME stress levels

Are you right or left handed?

Right

Left

What is your main intention for this treatment? (e.g. to work a particular area, to feel more energised, calm, grounded, mobile etc.)

Informed Consent

How your information will be used

I take your privacy very seriously; your personal information will only be used for treatment purposes with Mello and will never be shared with any third parties, without express permission.

From time to time, I might get in touch with special offers and mello news that I think might be of interest to you. If you agree to being contacted in this way, please tick the box

If you opt-in, you can change your preferences or remove your consent at any time by getting in touch with me or selecting 'unsubscribe'.

Disclaimer

I confirm that I have understood the treatment that I am to receive and confirm that I am willing to proceed without confirmation from my GP or consultant. By signing this form below, I hereby indemnify the therapist against any adverse reaction sustained as a result of the treatment. I agree that my medical history is accurate and correct.

Today's Date

Signature

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