Reflexology Health History Form Page 4
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4REFLEXOLOGY HEALTH HISTORY
720-254-6335
Sores on penis or scrotum
Men:
Hernia
Burning/discharge on urination
Impotence
Lumps/swelling of testicles
Other:___________________________________
Pain in prostate or testicles
Women:
Menopause:
Menses:
Do you think you have started?
Yes
No
Irregular cycle time frame:_________________________
Do you have periods?
Yes
No
Spotting
Frequency and duration
Hot flashes
Amount of bleeding: scant, average, heavy, spotting
Color: bright red, dark red, pink
Vaginal dryness/itching
Depression
Clots? Color:_______________
Other:
Bleeding between periods
______________________________________________
Other:
______________________________________________
Childbirth:
Number of pregnancies: __________________________
PMS:
Breast Lumps
Number of births:_______________________________
Sore breasts
Miscarriages:
Yes
No
Irritable
Premature births
Depressed
Cesareans
Emotional swings
Abortions
Bloating
Other:
Other:
______________________________________________
______________________________________________
Infections:
Vaginal pain/rash/irritation
Vaginal discharge Color:__________________________
Other: __________________________________________
Other: ___________________________________________________________________________________________________
Cancellation Policy:
So that I may better serve my clients, 24 hrs. notice is required for cancellation. You will be charged the full session with less than
24 hrs. notification.
Disclaimer:
1.
I understand that this work does not constitute nor it is a substitute for medical treatment, but rather is a form of health
maintenance. I realize that this therapist is not a doctor, and does not diagnose, prescribe or treat any specific conditions.
2.
I understand and agree that I am responsible for keeping my therapist informed of any changes in my physical condition,
as this could affect the treatment I receive.
Signature:_________________________________________________________Date:_______________________________
(Do not write below this line)
Notes:
____________________________________________________________________________________
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2010 Rachel Lord and Isabelle Hutton
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