Read Reflexology consultation sheet text version


Clients name

Reflexology Consultation Sheet

Doctors name Doctors address

Visit number

Clients address

Telephone D.O.B.



Number of children Cigarettes Alcohol

Marital status (delete as applicable)

Medication (including HRT and birth control), Self medication/Vitamins etc. Other therapies/treatments being undertaken Diet Poor / Average / Good Regular meals Major illness

Yes / No If yes, how many per day?

Yes / No If yes how many units on average per week

Pregnant Yes / No If yes, for how long?

Married / Single / Separated / Divorced / Widowed

Reason for visit




Fluid intake

State of health at present Major operations

Poor / Average / Good Food supplements

Yes / No

Yes / No

Accidents/Injuries/physical handicaps

Personality Regular exercise Yes / No. If yes in what form Sleep patterns Stress Glasses /10 Anxiety

Energy levels

Do you or a close relative suffer from any of the following conditions Epilepsy Thrombosis Migraine Allergies P.M.S. Headaches Diabetes Kidney/Bladder Heart/Chest Digestive/Bowel Asthma Back problems

Yes / No Lens

Good / Average / Poor

Yes / No Hearing aid

/10 Depression

hrs daily Yes / No


Condition of feet Colour

Regular Periods

Yes / no Date of last period Right Foot

Blood pressure Sinus/Ear Varicose Veins Skin problems Cancer Arthritis

Skeletal Condition

Left Foot

Muscle tone/flexibility Flat foot/high arch Hard skin build up Temperature Nail & Skin condition Position of foot fall

Client Signature

I, the undersigned agree that the information above is to the best of my Knowledge accurate and true and I hereby give my consent to the therapist named below to carry out Reflexology treatments upon me. Lynda Bowen Aomatherapy I.T.E.C (dip, A & R) T.A.Th. 2, Medway Terrace, Maidstone Rd., Wateringbury, Maidstone, Kent. ME18 5EL Therapists Signature

Distinguishing marks/scars


Reflexology consultation sheet

2 pages

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