Client Information Form Please enable JavaScript in your browser to complete this form.First & surname? *Date of Birth? *DD/MM/YYYYFirst line of your home address & postcode? *Telephone number? *Email? *EmailConfirm EmailPlease choose a therapy? *Select from dropdownReflexologyIndian head massageReflexology & Indian head massageFacialFacial & Indian head massageOccupation? *Name of next of kin? *Name of GP practice? *Any medication taken? *Only complete if having Reflexology &/or Indian head massage: If yes please tick box(es), or tick none of the aboveUndiagnosed painAllergiesDiabetesEpilepsyDeep vein thrombosisPulmonary embolismOsteoporosisAny heart or blood pressure issuesVaricose veins / phlebitis in treatment areaImminent medical tests or proceduresRecent surgeryInjury or condition linked to area to be treatedRecent haemorrhageMuscle disordersDysfunction of nervous systemMigranesNONE OF THE ABOVEOnly complete if having Uplifting Holistic Facial: If yes please tick box(es), or tick none of the aboveMigraines with auraEpilepsy, severe acneSevere acneFacial fillersBotoxContagious or open woundsLater stage of pregnancy (due to lying in the supine position)NONE OF THE ABOVEIf you have answered yes to any of the medical conditions, please give details:Do you have athlete's foot or another contagious foot condition? *Select from dropdownNoYesDo you suffer from any skin disorders or scalp infections? *Select from dropdownNoSkin disorderScalp infectionsHow is your diet? *What do you drink a day? *I.e. water, tea, coffee (caffeinated or decaffeinated)Are you smoker? *Select from dropdownNoYesDrink alcohol? *Select from dropdownNoYesDo you exercise? *Select from dropdownNoYesDo you find it easy to relax and how do you relax? *Describe your sleep pattern? *How would you rate your energy levels from 1-10? *How would you rate your stress levels from 1-10? *Any other relevant informationReason for seeking reflexology, Indian head massage &/or facial?I am pregnant or trying to get pregnant? I have discussed this with my reflexologist and I understand that while there is a natural chance of miscarriage throughout pregnancy but especially in the first trimester, there is no evidence that reflexology causes miscarriage, or provokes early labour. I am happy to go ahead with the treatment. *Select from dropdownNo I am not pregnant or trying to get pregnantYes I am pregnant or trying to get pregnantI declare the information in this form to be true, and accept that it is my responsibility to keep my practitioner updated regarding any changes to my health or medication. I am happy to receive reflexology and any other therapies as listed above. *Parental signature if client is under 16 years oldSubmit
