Marion Jenkins Therapies – Reflexology Client Intake Form

Marion Jenkins Therapies — Reflexology Client Intake Form
Please complete all sections honestly and to the best of your knowledge.

First Name

Last Name

Email *

Phone *

Address *

City *

County *

Postal Code *

Date of Birth *

Current Height *

Current Weight *

For insurance purposes: Our treatment bed holds a maximum of 16st / 114.3kg.

How did you hear about us?

Are you taking any medication? *

Yes No

If you answered YES, please give details:

Medication details

Please list allergies or sensitivities *

Are you currently pregnant?

Yes No

If you answered YES please answer the next two questions:

How many weeks pregnant are you?

Are there any risk factors to your pregnancy?

Yes No

If you answered YES to the above question please state:

Pregnancy Risks

Do you suffer from chronic pain? *

Yes No

If you answered YES to the above, please answer the following questions:

Chronic Pain — please describe

What makes the Chronic Pain better?

What makes the Chronic Pain worse?

Please tick the list below & tick any which are applicable

Why are you seeking reflexology today?

What are your goals for this Reflexology session?

Please can you identify any areas of discomfort using the drop-down list for the Left & Right foot below the image of feet:

Left Foot — Areas of Discomfort

Right Foot — Areas of Discomfort

Additional foot notes

BY SUBMITTING THIS FORM, you agree to the following:

I have completed this form to the best of my ability and knowledge, and agree to inform my practitioner if any of the above information changes at any time.

Please Sign Below *

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Reflexology Form