Reflexology Treatment

Thank you for taking the time to fill out this form for the upcoming treatment. We’re looking forward to providing you with the ultimate spa experience. All of the information provided is confidential and will only be shared with the spa party coordinator and the technician performing your service. Your privacy and safety is our utmost concern. Please feel to contact us if you have any questions.

Client Intake Form

Client Information
Name*
First Last
Date of Birth*
Date Format: MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
Emergency Contact:*
First Last
Phone*
Relationship to you?
Referred by:
First Last
What is your occupation?
Years in current occupation?
Medical Information
1. Are you currently under the care of physician?*
- Yes
- No
If yes, please explain.
2. Please list any medications you are currently taking and the condition for which you are taking them. (Ex: Medication - Albuetrol Condition - Asthma)
3. What injuries or accidents, if any, have you had within the past 10 years?
4. Have you ever had any back or joint injuries or surgeries? If so, describe.
5. Are you pregnant?*
- Yes
- No
6. Are you on birth control or hormone replacement therapy?*
- Yes
- No
If yes, please list name?
7. Endocrine - Please check any of the following medical diagnosis*
- Diabetes - Type 1 or 2
- Addison's Disease
- Cushing's Syndrome
- Osteoporosis
- Grave's Disease
- N/A
8. Cardiovascular - Please check any of the following medical diagnosis*
- Blood Cots
- Congenital Heart Disease
- Heart Attack
- High Blood Pressure
- Low Blood Pressure
- N/A
9. Neurological - Please check any of the following medical diagnosis*
- Alzheimer's or Dementia
- Anxiety
- Brain Injury or Tumor
- Depression
- Epilepsy
- Headaches/Migraines
- Neuropathy
- Numbness
- Psychological - Anxiety, Depression, OCD, etc
- Vertigo
- N/A
10. Skin - Please check any of the following medical diagnosis*
- Dermatitis
- Eczema
- Hives
- Vitiligo
- Seborrheic Dermatitis
- N/A
11. Immunology - Please check any of the following medical diagnosis*
- Allergies - Seasonal
- Asthma
- Infectious Disease (i.e. HIV)
- Lupus
- Sinus Problems
- N/A
12. Musculoskeletal - Please check any of the following medical diagnosis*
- Arthritis - Any form
- Bone Fractures
- Carpal Tunnel Syndrome
- Fibromyalgia
- Muscle / Tendon strain
- Ligament Sprain
- Ruptured / Herniated Disc
- Tendonitis
- N/A
13. Digestive - Please check any of the following medical diagnosis*
- Gastroesophageal Reflux Disease (GERD)
- Gallstones
- Celiac Disease
- Crohn's Disease
- Ulcerative Colitis
- Irritable Bowel Syndrome
- Hemorrhoids
- Diverticulitis
- N/A
14. Please list any any other conditions that have not been accounted for in the above questions.
15. Do you smoke?*
- Yes
- No
If yes, how many per day?
Reflexology Treatment
1. Have you ever had a reflexogy treatment before?*
- Yes
- No
2. What brings you in for bodywork today?*
- Relaxation
- Pain Relief
- Sports performance/recovery
- Health Maintenance
- Other
If you selected "other", please explain
3. Are you in pain?*
- Yes
- No
please describe
4. Have you seen a physician or medical practitioner for this condition?*
- Yes
- No
If yes, whom, when, and what diagnosis were you given?
5. How long have you had this condition?
6. What do you think caused this condition?
7. What makes the condition worse?
8. What makes the condition better?
9. Do you have any questions about the bodywork to be performed today?*
- Yes
- No
Photography Policy*
I agree to the photography policy.
I give permission for photographs to be used by Synergy Skin Care & Spa for educational and/or promotional purposes. Complete client confidentiality will be maintained at all times.
Name*
First Last
Because a reflexologist should be aware of existing physical conditions, I have stated all my known medical conditions and take it upon myself to keep the reflexologist updated on my physical health. My digital signature gives consent for the session and acknowledges that reflexology is not a substitute for medical examination or treatment. It is recommended that I see a physician for any physical ailment that I might have. I understand that the reflexologist does not diagnose, prescribe, treat, nor cure any illness, disease, or other physical or mental disorder. Likewise the reflexologist does not prescribe medical treatment or pharmaceuticals, nor do they perform spinal adjustments. By signing this form, I waive any and all claims, damages, action and liabilities against Synergy Skin Care & Spa arising out of or relating to reflexology, hand/foot treatments, and allergic reactions to services performed. In the event a dispute arises over the outcome of my procedure, I consent solely to arbitration as a legal means of settlement. I understand English, or if I do not, I have appointed someone to translate this consent form in its entirety. I am eighteen years of age (18) or older. My digital signature indicates my consent for the reflexologist and selected associates to contact me via mail, email, and phone.
Date*
Date Format: MM slash DD slash YYYY
Comments
This field is for validation purposes and should be left unchanged.

Reflexology Treatment

Client Intake Form

Client Information

Medical Information

Reflexology Treatment