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Reflexology Taster Treatment Form

To assist your Health Review with us, we ask that you please complete this questionnaire as fully as possible.

Name *

Phone Number *

Email *

Address *

Contraindications - Active DVT or pulmonary embolism – do not treat until the condition is stable - Fever or contagious condition – risk assessment and make a decision - Cellulitis or other skin condition affecting the area to be worked – avoid the affected area

Cautions

Acute undiagnosed pain *

YES
NO

Allergies *

YES
NO

Diabetes *

YES
NO

Epilepsy *

YES
NO

Osteoporosis *

YES
NO

Unstable heart or blood pressure *

YES
NO

Varicose veins *

YES
NO

Injury or condition in treatment area *

YES
NO

If you have any of the above, please discuss with your reflexologist before your taster session.

If you have any ongoing medical conditions or are on any medication, please provide more details here: *

Pregnancy Disclaimer *

I am pregnant or trying to get pregnant. I have discussed this with my reflexologist and I understand there is no evidence that reflexology causes miscarriage. I am happy to go ahead with the taster session.

GDPR Policy *

I agree to the GDPR policy of the practitioner.

Declaration *

I declare the information in this form to be true. I consent to receive a reflexology taster session.

Signed *

Date *

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Each health screening test is carried out by a pharmacist taking a finger prick of blood from your finger. The blood is then placed in a device or machine. The results will then be interpreted by the pharmacist and advice & guidance given. In the majority of cases the results take 10 minutes.

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