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Reflexology Intake Form

This document is a reflexology intake form that collects personal and health information from a new client. It requests contact details, medical history including medications, injuries and conditions, as well as information on the client's goals and reasons for seeking reflexology. Ratings of sleep, energy, stress, nutrition and exercise are also collected. By signing, the client agrees to provide accurate information and update the reflexologist if anything changes.

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Jael Pistio
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© © All Rights Reserved
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2K views1 page

Reflexology Intake Form

This document is a reflexology intake form that collects personal and health information from a new client. It requests contact details, medical history including medications, injuries and conditions, as well as information on the client's goals and reasons for seeking reflexology. Ratings of sleep, energy, stress, nutrition and exercise are also collected. By signing, the client agrees to provide accurate information and update the reflexologist if anything changes.

Uploaded by

Jael Pistio
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Reflexology Intake Form

Personal Information

Name ________________________________________ Phone (day) _____________________ (evening) _____________________

Address _____________________________________ City/State/Zip _________________________________ DOB ___________

Occupation _____________________________________________ Employer ___________________________________________

Email _______________________________________________ Primary Physician _______________________________________

Emergency Contact ____________________________________ Relationship __________________ Phone __________________

How did you hear about us? ____________________________________________________________________________________

Health Information Treatment Information


Are you taking any medications? ☐ yes ☐ no
Have you had Reflexology before? ☐ yes ☐ no
If yes, please list name and use: _____________________
Why are you seeking Reflexology today?
_______________________________________________
________________________________________________
Are you currently pregnant? ☐ yes ☐ no ________________________________________________
If yes, how far along? ______________________________ What are your goals for this session?
Any high risk factors? ______________________________ _____________________________________________
Do you have any allergies or sensitivities? ☐ yes ☐ no Please circle any areas of discomfort:
Please explain ________________________________
Have you had any recent injuries? ☐ yes ☐ no
If yes, please list: ________________________________
Please indicate any of the following that apply to you.
☐ Cancer ☐ Fibromyalgia
☐ Headaches/Migraines ☐ Stroke
☐ Arthritis ☐ Heart Attack
☐ Diabetes ☐ Kidney Dysfunction
☐ Joint Replacement(s) ☐ Blood Clots
☐ High/Low Blood Pressure ☐ Numbness
☐ Neuropathy ☐Sprains or Strains

Explain any conditions you have marked above:

________________________________________________
________________________________________________

Please rate the following on a scale of 1(bad) – 5(excellent) By signing below, you agree to the following.
I have completed this form to the best of my ability and
Quality of Sleep 1 2 3 4 5 knowledge and agree to inform my Reflexologist if any of the
Energy Levels 1 2 3 4 5 above information changes at any time.

Stress Levels 1 2 3 4 5
Client Signature __________________________ Date __________
Quality of Nutrition 1 2 3 4 5
Reflexologist Signature _____________________ Date _________
Exercise Habits 1 2 3 4 5

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