775497991
 
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