Reflexology Health History Form Page 3

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REFLEXOLOGY HEALTH HISTORY
720-254-6335
Caffeine
How many a day?____
How much?_____
Describe:_______________
Salt
How long?____________
How long?______
_______________________
SYMPTOM SURVEY
Check and fill in if applicable
Other: ____________________________
General:
General Fatigue
Loss of or excessive gain in weight
Average hours of sleep per night______
Urinary:
Quality of sleep: Good; Fair; Poor
Frequent urination
Insomnia
Involuntary escape of urine
Motion Sickness
Burning/discharge on urination
Other:___________________________________________
Weak urine stream
Difficulty starting urine
Respiratory:
Constant urge to urinate
Sinus Problems
Bedwetting
Difficulty breathing deeply
Flank pain
Nosebleeds
Number of times awaken in night to urinate___________
Frequent coughing
Frequent urinary tract infections
Frequent colds/sore throats
Other:_________________________________________________
Other:_________________________________________________
Senses:
Cardiovascular:
Glasses/Contact Lenses
Rapid or skipped beats
Eyesight worsening
Varicose veins
Hearing difficulties
Bruise easily
Earaches
Chest pain
Ringing in ears
Cold hands/feet
Dizzy/loss of balance
Shortness of breath with activity
Other:___________________________________________
High blood pressure
Other:_________________________________________________
Digestive:
Frequent indigestion
Neuromuscular:
Heartburn
Headaches
Muscle pain Where? __________________________________
Gas/bloating
Muscle cramping
Nausea/vomiting
Weakness in arms or legs
Abdominal cramps
Swollen joints
Frequency of bowel movements_____________________
Painful joints
Alternating constipation/diarrhea
Frequent dislocations
Consistency of stools: hard, firm, soft , loose
Jaw/pain tension (TMJ)
Pain/itching in rectum
Frequent bone fractures
Hemorrhoids
Memory loss
Excessive or loss of appetite
Absent minded
Other:___________________________________________
Numbness/tingling
Where?______________________________
Endocrine:
Other:___________________________________________
Swollen glands
Skin
Excessive thirst, hunger, sweating, urination
Skin eruptions
Slow/fast metabolism
Excessive sweating Where?___________________
Blood sugar imbalances
Dry or oily skin
Thyroid problem such as low energy
Other: ___________________________________________
Hair loss
 2010 Rachel Lord and Isabelle Hutton
3

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