Confidential Health History Form Page 2

HEALTH INFORMATION

If there are any questions that you don’t feel comfortable answering, please leave the section blank and we

can discuss this in person.

Why are you trying Reflexology?

______________________________________________________________________________________

Where is tension most evident in your body?

Are you currently being treated for a medical condition? (Please describe)

Have you ever had a Reflexology treatment?

Yes

No When and for what reason?

Are you sensitive to essential oils, body oils and/or creams?

Yes

If yes, describe:

List any medications (prescription and over-the-counter), vitamins, and/or supplements you are

currently taking, as well as, medications you have taken in the past:

Name

Dosage/Frequency

How long

Reason

HOSPITALIZATIONS/Surgeries/Operations (list dates):

The Barefoot Dragonfly•11673 Jollyville Rd, Suite 201 • Austin, TX • 78759 • 512-666-9374 •

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Parent category: Medical