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Reflexology Client Consultation Form (Pregnancy & Maternity)
Please select any applicable:
Acute Undiagnosed Pain
Cardiovascular Condition
Allergies
Varicose Veins/Phlebitis
Diabetes
Imminent Medical Tests/Procedures
Epilepsy
Recent Surgery
Osteoporosis
Injury to the Feet or Foot Condition
None
Have you received your Covid-19 vaccinations?
Yes
No
Have You or Are You Suffering From the Following?
Backache
Groin Pain
Heartburn
Diarrhoea
Frequent Micturition
Anaemia
Deep Vein Thrombosis
High Blood Pressure
Sciatica
Itchy Skin
Fatigue
Symphysis Pubis Pain
Braxton Hicks Contractions
Morning Sickness
Constipation
Protein, Sugar or Blood in Urine
Leg Pain/Cramp
Low Blood Pressure
Oedema
Carpal Tunnel Syndrome
Stretch Marks
Diabetes
Rib Pain
Vaginal Bleeding
Food Fads/Cravings
Cystitis
Palpitations
Varicose Veins
Haemorrhoids
Panic Attacks
Headaches
Tender Breasts
Mood Swings
Insomnia
Just so I have the correct chair/couch set-up for your session, please tell me if you are:
Height: over 175cm?
Weight: over 115kg?
I am pregnant or trying to conceive. 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.
I declare the information in this form to be true, and accept that it is my responsibility to keep my practitioner updated regarding any changes in my health or medication. I am happy to receive Reflexology and any other therapies as listed above. (You will be presented with a copy of this consultation form, for your signature, at your appointment).
I understand that Reflexologists do not claim to cure, diagnose or prescribe, and that Reflexology should not be used as an alternative to seeking medical advice. Always consult your medical professional/GP.
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