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Intake Form

THIS FORM IS TO BE COMPLETED BY THE CLIENT FIRST THEN BY PRACTITIONER FOR INITIAL SESSION

Informed Consent

To the Clients of Reflexology, you need to know that:

1. I am not a doctor.

2. I do not practice medicine.

3. I do not diagnose or treat for a specific illness

4. I do not prescribe or adjust medication

5. Reflexology is not a substitute for medical treatment, but is a complement to most types of therapy.

What is Reflexology?

Reflexology is a natural therapeutic approach based on the idea that specific reflex points in the body correspond to different parts, glands, and organs. By applying pressure to these reflex areas, reflexology can relieve tension, enhance circulation, and support the body's ability to function optimally.

 

Reflexologists believe the entire body is mirrored on the feet and hands. Foot and hand reflexology is a scientific art based on the premise that there are zones and reflex areas in the feet, and hands, which correspond to all body parts. The physical act of applying specific pressures using thumb, finger, and hand techniques, results in stress reduction, which causes physiological changes in the body. A primary benefit of reflexology is relaxation. Relaxation through reflexology may help the body to balance any kind of stress it is experiencing.

What does Reflexology do?

1. Reflexology promotes balance and normalization of the body naturally.

2. Reflexology reduces stress and brings about relaxation; and

3. Reflexology stimulates circulation and the delivery of oxygen and nutrients to the cells.

Contract For Services

By filing out the form below, I give my consent to a Reflexology session with Dawn, at Hannah Reflexology. I understand I may discontinue a session or sessions at any time. I further understand that I must disclose at this time if I am a government official or representing any news media. If I have been diagnosed by a licensed health professional as having any disease, injury or other physical or mental condition, I understand that reflexology sessions are not a substitute for any treatment or therapy previously ordered, prescribed, or recommended by that health professional.

Birthday
Year
Month
Day
Are you in good health?
Yes
No
Are you undergoing other therapies?
Yes
No
Are you taking medications? Please include any vitamins or dietary supplements.
Yes
No
Do you sleep well?
Yes
No
Do you suffer from anxiety or worry?
Yes
No
Is your blood pressure:
Are you pregnant?
Yes
No
If yes, which trimester?
Have you had other pregnancies?
Yes
No
Do you have allergies/sinus conditions?
Yes
No
Do you have varicose veins?
Yes
No
Do you wear prostheses?
Yes
No
If Yes, Please Check all that apply:
Is there anything else about your health you wish to discuss?
Yes
No
Are you presently experiencing any of the following?

Please indicate your consumption level of the following by placing an X in the appropriate column.

Salt
None
Light
Moderate
Heavy
Sugar
None
Light
Moderate
Heavy
Caffeine
None
Light
Moderate
Heavy
Tabacco
None
Light
Moderate
Heavy
Alcohol
None
Light
Moderate
Heavy
Canabis
None
Light
Moderate
Heavy
Exercise
None
Light
Moderate
Heavy
Water
None
Light
Moderate
Heavy
Have you ever had reflexology before?
Yes
No
Date of last treatment:
Year
Month
Day
Have you ever been treated for?
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