The BodyWorkshop Reflexology Consultation Form by vPVG3Lr

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									Reflexology Consultation Form




Name:                                                      ____                   D.O.B:


Address:                                                                                                                     ______

______________________________________________________________________________________________

______________________________________________________________________________________________


E-mail:                           _____________________


Tel: __________________________________________                                   Mobile: _______________________________



Height: _____________________________________                                     Weight: ______________________________


Marital Status: _________________________________                                 Children?: ____________________________


Occupation:


Interests:                                                                                   ______________________________




Medical History

Please give details of past medical conditions, including falls, accidents, operations i.e. heart, circulation, respiratory
etc.




              t : 07961 919 693   e : info@thebodyworkshop.org.uk   a : No. 1, Building 37, Cadogan Road, London, SE18 6RB

                                                   w: www.thebodyworkshop.org.uk
Present Health

Are you aware of any current health issues that you may be seeing another practitioner or taking medication for? Any
other concerns?




Allergies:                                                                                   ______________________________


Do you experience headaches or tension anywhere in your body? When?

______________________________________________________________________________________________

______________________________________________________________________________________________


Please give a comment or two on:


Your normal diet:                                                                            ______________________________

                                                                                             ______________________________

                                                                                             ______________________________


Exercise, sleep patterns, general energy levels?:                                            ______________________________

                                                                                             ______________________________

                                                                                             ______________________________


Do you think you may be pregnant?:                                                           ______________________________



                    I declare the above statements to be true to the best of my knowledge.




Client Signature: _____________________________                              Date: ________________________________


Susan Archer MAR is a Full member of the Association of Reflexologists and is required to abide by the Association’s
Code of Practice and Ethics, a copy of which is available on request.



Therapist Signature: _____________________________                           Date: ________________________________


              t : 07961 919 693   e : info@thebodyworkshop.org.uk   a : No. 1, Building 37, Cadogan Road, London, SE18 6RB

                                                   w: www.thebodyworkshop.org.uk

								
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