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Reflexology Client Consultation Form (Reproductive)
Are you:
Single
Heterosexual Couple
Same Sex Couple
Caution Check:
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
Was it on time?
Yes
No
What was the flow like?
Light
Medium
Heavy
Any Spotting (select all applicable)
Before Period
After Period
During Cycle
Any Fertility Difficulties?
Yes
No
Previous or Current Fertility Treatment(s):
Clomid/Medical Cycle
IVF/ICSI
IUI
Do you or have you suffered from any of the following? (Please tick any that apply either currently or previously)
Amenorrhoea (no periods)
Irregular Periods
Anovulation
Low Back Pain
Malformed Womb
Ovulation Pain
Cystitis
Ovarian Cysts
Endometriosis
Andometriosis
Fallopian Tube Issues
Pain on Intercourse
Painful Periods
PMS
Thrush
Fibroids
Genital Ulcers
Water Retention
Vaginal Discharge/Burning/Irritation
Have you been checked or previously treated for:
AIDS
Gonorrhoea
Strep B
Herpes
Candida
Cervical Erosion
Chlamydia
Genital Warts
Syphilis
Trichomonas
Contraception (please tick any of the following):
Coil
Diaphragm
Female Condom
Natural Family Planning
OCP
Sponge
Condom
None
Choice 1
Are you currently taking any of the following? (Please tick any that apply)
Antidepressants
Painkillers
Diuretics
Sleeping Tablets
Steroids
Laxatives
Supplements
Tranquillizers
Did You Suffer Any of The Following Ailments?
Back Ache
Groin Pain
Heartburn
Diarrhoea
Frequent Micturition
Anaemia
Deep Vain 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 Attack
Headaches
Tender Breasts
Mood Swings
Insomnia
Was the Baby:
Pre-term
On Time
Overdue
Upload File
Upload supported file (Max 15MB)
Caution Check:
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
Upload File
Upload supported file (Max 15MB)
Have you had any of the following?
Mumps
Non-specific Urethritis
Rubella
Testicular Cancer
Varicocele
Vascetomy Reversal
Have you been checked or previously treated for:
AIDS
Gonorrhoea
Herpes
Candida
Chlamydia
Genital Warts
Syphilis
Trichomonas
Are you currently taking any of the following? (Please tick any that apply)
Antidepressants
Painkillers
Diuretics
Sleeping Tablets
Steroids
Laxatives
Supplements
Tranquillizers
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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