Reflexology New Patient Form

REFLEXOLOGY HEALTH RECORD
THIS FORM IS TO BE COMPLETED BY THE CLIENT FIRST THEN BY PRACTITIONER FOR INITIAL SESSION
Date of
Client Birth
Telephone Home Business Ext

Email
Address
Street
N
a
m
Street # e
Provinc Postal
City e Code
Doctor’s Name Telephone

Doctor’s
1.Address
What is your occupation?
2. Are you in good health? Yes No Explain: _______________________________________
3. Are you undergoing other therapies? Yes No
List
4. What else are you doing for your health?
5. What are your goals/expectations for this session?
6. When did you last visit your doctor?
Reason
7. List past surgeries and time of same:
8. List past injuries and time of same:
9. Are you taking medications? (Please include any vitamins or dietary supplements.) Yes No
Reasons for taking:
10. Do you sleep well? Yes No
Explain:
11. Do you suffer from anxiety or worry? Yes No
REFLEXOLOGY ASSOCIATION OF CANADA © 2006

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Explain:
12. Is your blood pressure: Normal High Low Stable Erratic
13. Are you pregnant? Yes No If yes, which trimester? 1st 2nd 3rd
14. Have you had other pregnancies? Yes No
15. Do you have allergies/sinus conditions? Yes No
List:
16. Do you have varicose veins? Yes No
17. Do you wear prostheses (e.g. glasses, contacts, glass eye, artificial joints/limbs, metal plates, pins,
or wires, dentures, hearing aids?) Yes No Circle which one
18. Is there anything else about your health you wish to discuss? Yes No
Explain:
19. Are you presently experiencing any of the following?
Sunburn Inflammation Pain Headache Skin Rash Cold/Flu
Cuts Bruises Burns Decreased Range of Motion
Other:
20. Please indicate your consumption level of the following by placing an X in the appropriate column.
None Light Moderate Heavy

Salt
Sugar
Caffeine
Tobacco
Alcohol
Exercise
Water
Consent to Receive Treatment

I, the undersigned, consent to reflexology treatment and understand that sessions are for
the purpose of stress reduction and relaxation. I may stop the session at anytime, either
during the assessment or the treatment.
Reflexologists do not diagnose, prescribe medication for medical or psychological
conditions, nor treat for specific conditions.
Signature: ______________________________ Date: ____________________________

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Do you have problems with any of the following systems?
Endocrine System (diabetes, hypoglycemia, menopausal problems, hypothyroidism) Yes No

Specify:
Urinary System (kidney disease, urinary problems) Yes No
Specify:
Cardiovascular (high/low blood pressure, heart disease, phlebitis, varicose veins, Yes No
circulation problems, anemia, etc.)
Specify:
Immune & Lymphatic (arthritis, chronic fatigue, environmental illness, HIV/AIDS, Yes No
allergies, etc.)
Specify:
Musculoskeletal (osteoporosis, fibromyalgia, bursitis, gout, back pain, scoliosis Yes No
foot, arm or hand problems)
Specify:
Respiratory (asthmas, emphysema, etc.) Yes No
Specify:
Nervous System (vision, hearing loss/problems, loss of sensation, Yes No
nerve pain/damage, mental or emotional problems, MS)
Specify:
Reproductive (PMS, dysmenorrhea, endometriosis, prostate problems, etc.) Yes No
Specify:
Digestive (prolonged constipation, diarrhea, Crohn’s Disease, Yes No
Colitis, diverticulitis, ulcer, etc.)
Specify:
Integumentary (Skin) (Psoriasis, eczema, warts, etc.) Yes No
Specify:
Other
Tuberculosis Yes No Cancer Yes No Aids Yes No
Hepatitis Yes No Herpes Yes No
If a client is experiencing pain, use the reminder phrase OL DR FICARA, when questioning the client to determine the
following:
Onset? Duration? Frequency? Character (dull, sharp, etc.)? Relieving Factors?

Location? Radiation? Intensity? Aggravating Factors? Associated Symptoms?

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REFLEXOLOGY INITIAL TREATMENT RECORD
NOTE: A GLOSSARY OF SYMBOLS MUST ACCOMPANY THIS PAGE FOR REFERENCE
Client:
Date of Initial Session:
Client Signature: ____________________________________

Page 4 of 7
All questions to be completed for each session-use ‘Notes’ page if needed
Client Name and Client Signature:
Session: Date:
Felt Last Treatment
Felt Since Treatment
Feels Today
Observations of Client
Foot Observations
Right
Left
Findings During Treatment
Action Taken
Results
Clients Comments
Final Observations
Treatment Notes –

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For Health Record & Session Notes

Page 7 of 7

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REFLEXOLOGY HEALTH RECORD

Telephone Home Business Ext

Doctor’s Name Telephone

2. Are you in good health? Yes No Explain: _______________________________________

3. Are you undergoing other therapies? Yes No

4. What else are you doing for your health?

5. What are your goals/expectations for this session?

6. When did you last visit your doctor?

7. List past surgeries and time of same:

8. List past injuries and time of same:

Reasons for taking:

10. Do you sleep well? Yes No

11. Do you suffer from anxiety or worry? Yes No

REFLEXOLOGY ASSOCIATION OF CANADA © 2006

12. Is your blood pressure: Normal High Low Stable Erratic

14. Have you had other pregnancies? Yes No

15. Do you have allergies/sinus conditions? Yes No

16. Do you have varicose veins? Yes No

19. Are you presently experiencing any of the following?

Sunburn Inflammation Pain Headache Skin Rash Cold/Flu

Cuts Bruises Burns Decreased Range of Motion

None Light Moderate Heavy

Consent to Receive Treatment

Signature: ______________________________ Date: ____________________________

REFLEXOLOGY ASSOCIATION OF CANADA © 2006

Endocrine System (diabetes, hypoglycemia, menopausal problems, hypothyroidism) Yes No

Onset? Duration? Frequency? Character (dull, sharp, etc.)? Relieving Factors?

REFLEXOLOGY ASSOCIATION OF CANADA © 2006

Date of Initial Session:

Client Signature: ____________________________________

REFLEXOLOGY ASSOCIATION OF CANADA © 2006

Client Name and Client Signature:

Felt Last Treatment

Felt Since Treatment

Findings During Treatment

REFLEXOLOGY ASSOCIATION OF CANADA © 2006

REFLEXOLOGY ASSOCIATION OF CANADA © 2006

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Signature: __ Date: