Reflexology Health History Form
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4REFLEXOLOGY HEALTH HISTORY
720-254-6335
Last Name:____________________ First Name: _______________________Date____________________
Address:___________________________________ City: _____
State:_________ Zip _______________
Phone: Home:______________________Work:____________________Cellular:_____________________
E-Mail address: __________________________________________________________________________
Date of Birth: ________________________Age: _________________Place raised:____________________
Married
Single
Divorced
Significant Other
Widow
Height: ________Weight:_______ Desired weight: ____________
Allergies:_______________________________ Sensitivities:_____________________________________
Occupation:__________________________________Employer:___________________________________
Emergency Contact: ________________________ Relationship: ___________________Phone___________
Referred By: ____________________________________________________________________________
Children: Name(s), Age(s), Living with you?___________________________________________________
_______________________________________________________________________________________
Are you currently under a doctor’s care? _________For what? _____________________________________________
Current practitioners:
Name:________________________Address:________________________________Phone:_____________________
_____________________________
____________________________
______________________
Reflexology Treatment Goals: (physical, emotional, etc)
1. ________________________________________________________________________________________
2. ________________________________________________________________________________________
3. ________________________________________________________________________________________
Have you ever received reflexology or other bodywork sessions? __________________________________________
Specify: _____________________________________________How often: _________________________________
Stressors in your life: (Rate stress level 1-10; Ten is the worst.)
Family: ______ Social: ______Work related:______ Stress in your body? _____Other? ________________________
Where do you hold your tension? ____________________________________________________________________
Do you exercise? Yes
No
What? ________________How often? ____________How long?________________
Energy level and pattern? (least and most productive time of day)
_______________________________________________________________________________________________
Are you pregnant? ______________________________________Due date: _________________________________
Serious past illnesses? _____________________________________________________________________________
_______________________________________________________________________________________________
Accidents, Injuries and dates? _______________________________________________________________________
_______________________________________________________________________________________________
Hospitalizations and dates?_________________________________________________________________________
_______________________________________________________________________________________________
Current prescription medications?____________________________________________________________________
_______________________________________________________________________________________________
_____________________________________
Current herbs and supplements? ____________________________
_______________________________________________________________________________________
2010 Rachel Lord and Isabelle Hutton
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Parent category: Medical