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Reflexology Client Consultation Form
(Peri-menopause, Menopause & Post Menopause)
Caution Check (please tick applicabe)
Have you received your Covid-19 vaccinations?
How would you describe your current menstrual status?
Was your menopause:
HeadachesNoneMildModerateSevereExtremely SevereHeadaches
Weight GainNoneMildModerateSevereExtremely SevereWeight Gain
Thinning HairNoneMildModerateSevereExtremely SevereThinning Hair
MigrainesNoneMildModerateSevereExtremely SevereMigraines
Fungal InfectionsNoneMildModerateSevereExtremely SevereFungal Infections
Night SweatsNoneMildModerateSevereExtremely SevereNight Sweats
AnxietyNoneMildModerateSevereExtremely SevereAnxiety
Hot FlushesNoneMildModerateSevereExtremely SevereHot Flushes
Muscle WastingNoneMildModerateSevereExtremely SevereMuscle Wasting
InsomniaNoneMildModerateSevereExtremely SevereInsomnia
OverwhelmedNoneMildModerateSevereExtremely SevereOverwhelmed
Bursts of AngerNoneMildModerateSevereExtremely SevereBursts of Anger
Painful SexNoneMildModerateSevereExtremely SeverePainful Sex
Fatigue/No EnergyNoneMildModerateSevereExtremely SevereFatigue/No Energy
Increased Chin HairNoneMildModerateSevereExtremely SevereIncreased Chin Hair
Aches and Pains/StiffnessNoneMildModerateSevereExtremely SevereAches and Pains/Stiffness
Dry EyesNoneMildModerateSevereExtremely SevereDry Eyes
Digestive ProblemsNoneMildModerateSevereExtremely SevereDigestive Problems
Mood SwingsNoneMildModerateSevereExtremely SevereMood Swings
Itchy SkinNoneMildModerateSevereExtremely SevereItchy Skin
Cracked HeelsNoneMildModerateSevereExtremely SevereCracked Heels
Frequent UTIsNoneMildModerateSevereExtremely SevereFrequent UTIs
Irregular PeriodsNoneMildModerateSevereExtremely SevereIrregular Periods
Dry SkinNoneMildModerateSevereExtremely SevereDry Skin
BloatingNoneMildModerateSevereExtremely SevereBloating
Low LibidoNoneMildModerateSevereExtremely SevereLow Libido
Loss of MemoryNoneMildModerateSevereExtremely SevereLoss of Memory
Heart PalpitationsNoneMildModerateSevereExtremely SevereHeart Palpitations
Crying/WeepingNoneMildModerateSevereExtremely SevereCrying/Weeping
Panic Attacks NoneMildModerateSevereExtremely SeverePanic Attacks
Vaginal DischargeNoneMildModerateSevereExtremely SevereVaginal Discharge
Crawling SkinNoneMildModerateSevereExtremely SevereCrawling Skin
Acne/PimplesNoneMildModerateSevereExtremely SevereAcne/Pimples
Brain FogNoneMildModerateSevereExtremely SevereBrain Fog
Burning Tongue/MouthNoneMildModerateSevereExtremely SevereBurning Tongue/Mouth
Brittle NailsNoneMildModerateSevereExtremely SevereBrittle Nails
OverheatedNoneMildModerateSevereExtremely SevereOverheated
No PeriodsNoneMildModerateSevereExtremely SevereNo Periods
Craving SugarNoneMildModerateSevereExtremely SevereCraving Sugar
Feeling LowNoneMildModerateSevereExtremely SevereFeeling Low
Vaginal DrynessNoneMildModerateSevereExtremely SevereVaginal Dryness
OsteoporosisNoneMildModerateSevereExtremely SevereOsteoporosis
TinnitusNoneMildModerateSevereExtremely SevereTinnitus
Vivid DreamsNoneMildModerateSevereExtremely SevereVivid Dreams
ConstipationNoneMildModerateSevereExtremely SevereConstipation
DepressionNoneMildModerateSevereExtremely SevereDepression
GrumpyNoneMildModerateSevereExtremely SevereGrumpy
Loss of ConfidenceNoneMildModerateSevereExtremely SevereLoss of Confidence
IncontinenceNoneMildModerateSevereExtremely SevereIncontinence
Sore/Swollen BreastsNoneMildModerateSevereExtremely SevereSore/Swollen Breasts
Deepening VoiceNoneMildModerateSevereExtremely SevereDeepening Voice
Receding GumsNoneMildModerateSevereExtremely SevereReceding Gums
Tingling ExtremitiesNoneMildModerateSevereExtremely SevereTingling Extremities
AllergiesNoneMildModerateSevereExtremely SevereAllergies
Are your periods/were your periods usually regular?
Do you have:
Are your periods painful?
If yes, how painful?
Has your period recently become very heavy?
Is there a recent change in how often you have periods?
Is there a recent change in how many days you bleed?
Any PMS (mood swings, bloating, headaches before period)
Do you examine you breasts?
Have you had any of the following recently?

Thanks for submitting!