Reflexology Health History Form Page 2
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4REFLEXOLOGY HEALTH HISTORY
720-254-6335
Current Medical Concerns:
Asthma
Headaches
Multiple Sclerosis
Blood Clots
Heart Problems
Osteoarthritis
Breast Lumps
Hemophilia
Osteoporosis
Cancer
HIV
Rheumatoid Arthritis
Chronic Fatigue
Infections
Stomach ulcers
Diabetes
Liver Problems
Other:______________________
___________________________
Epilepsy
Lupus
Foot
Problems?_______Describe:___________________________
__________________________________________________
Bunion
Hammer Toe
Bone Spur
Ingrown toenail
Calluses
Puffiness
Claw toe
Scar, past injury
Corn
Unusual color, rash
Current injury, bruise
Wart
__________________________
Other:_____________
* Mark areas of concern on foot chart
Hand
Problems?_______Describe:___________________________
__________________________________________________
Calluses
Scar, past injury
Current injury, bruise
Unusual color, rash
Nail abnormality (cracked, ridges)
Wart
Puffiness
Other:______
* Mark areas of concern on hand chart
Left Hand
Right Hand
Ear
Problems?______ Describe_____________________________
___________________________________________________
Current injury, bruise
Scar, past injury
Puffiness
Unusual color, rash
Other:_______________________
____________________
* Mark areas of concern on ear chart
Right Ear
Left Ear
Wellness Continuum
Please mark where you think you fall on this wellness continuum
Sick
Your optimum health
Getting sick
OK
Good
or better
Addictions:
Sugar
Smoking
Alcohol
Drugs
2010 Rachel Lord and Isabelle Hutton
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Parent category: Medical