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Reflexology Intake Form

Section 1: Personal Information

First Name

Last Name

Date of Birth

Preferred Name

Contact Number

Email Address

Street Address

City

State/Province

Postal/Zip Code

Occupation

Section 2: Reason for Visit & General Health

Primary reason for seeking reflexology today: (Please describe your main goals, e.g., relaxation, stress relief, specific discomfort, general wellness)

Current general state of health:

Excellent

Good

Fair

Poor

Have you had reflexology before?

If yes, when was your last session and what was your experience?

Section 3: Medical History & Current Health Status

Please note: Reflexology is a complementary therapy and not a substitute for medical diagnosis or treatment. Always consult your primary healthcare provider for medical concerns.

 

Do you have, or have you ever been diagnosed with, any of the following? (Please check all that apply)

Diabetes

Heart Condition/Hypertension (High Blood Pressure)

Circulatory Disorders (e.g., DVT, thrombosis)

Epilepsy/Seizure Disorders

Osteoporosis/Brittle Bone Disease

Arthritis (Rheumatoid or Osteo)

Thyroid Condition

Cancer (Current or in remission)

Autoimmune Disorders

Skin Conditions/Contagious Infections (e.g., athlete's foot, plantar warts)

Other Chronic Illness:

Are you currently under the care of a doctor or other healthcare practitioner?

If yes, for what condition?

Practitioner's Name

Are you currently taking any prescription medication, over-the-counter drugs, or supplements?

If yes, list the names and reasons here.

Name

Reason

A
B
1
 
 
2
 
 
3
 
 
4
 
 
5
 
 

Do you have any allergies such as nuts, essential oils, or latex?

If yes, Please list all known allergies below.

 

For Women

 

Are you pregnant, or is there a possibility you could be pregnant?

Yes

No

Not Applicable

Are you currently breastfeeding?

Yes

No

Not Applicable

Section 4: Specific Areas of Focus & Contraindications

Do you have any current pain, discomfort, or injury in the following areas? (Please check and describe)

Body Part

Select

Description

A
B
C
1
Feet/Ankles
 
2
Lower Legs/Knees
 
3
Hands/Wrists
 
4
Back/Neck/Shoulders
 

Do you currently have, or have recently had, any of the following in your feet or legs?

Open wounds, sores, or recent surgery

Gout flare-up

Acute inflammation or infection

Phlebitis/Varicose Veins (severe)

Fungal infection (e.g., athlete's foot)

Bunions, corns, or verrucae (warts)

None of the above

Are there any areas on your feet you prefer I avoid or use less pressure?

If you selected yes, please provide the specific information here.

Section 5: Lifestyle & Well-being

How would you rate your current stress level? (1=Low, 10=High)

Sleep quality

Restful

Disturbed

Insomnia

Diet

Balanced

Irregular

Water intake (approx. glasses per day)

Exercise frequency (e.g., 3x/week)

Do you smoke?

Do you consume alcohol regularly?

Section 6: Consent & Agreement

I hereby voluntarily consent to receive reflexology therapy.

I understand that reflexology is a complementary foot/hand therapy that works on principle that there are reflexes in the feet/hands relative to all organs and systems of the body. It is intended to promote deep relaxation and a sense of well-being.

I understand that the practitioner does not diagnose medical conditions, prescribe, or treat for specific illnesses.

I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated on any changes in my health.

I understand that I, or the practitioner, may end the session at any time.

Client Signature

Therapist's Notes (Post-Session)

Therapist's Signature

Form Template Insights

Please remove this form template insights section before publishing.

Insights into the Reflexology Intake Form Template

1. Foundational Framework: Building the Therapeutic Relationship

  • Purpose: The form begins by establishing a clear, professional record. It transitions the client from the external world into the therapeutic space, signaling that their individual needs are the primary focus.
  • Key Insight: Collecting a preferred name fosters a personal connection. The "Reason for Visit" section is critical—it immediately centers the session on the client's own goals, whether for relaxation, specific support, or general wellness, ensuring the therapy is client-led.

2. Core Function: Ensuring Safety and Appropriateness

This is the most vital section of the form. Its primary role is to identify any situations where standard reflexology techniques might need to be adapted, delayed, or where focused communication with another healthcare provider is advisable.

  • Medical History Checkboxes: This is a quick-reference safety scan. Conditions like diabetes, circulatory disorders, or osteoporosis do not preclude therapy but directly inform pressure application, area focus, and session goals. For instance, gentle pressure may be indicated.
  • Current Medications & Practitioner Care: This provides context for the client's overall health landscape. It helps the practitioner understand potential sensitivities or systemic effects, reinforcing the form's role as part of an integrated approach to well-being.
  • Contraindications Focus (Feet/Legs): This direct question about local conditions (infections, wounds, gout flare-up) is a practical safety measure to protect both client and practitioner, ensuring the session is physically appropriate to proceed.

3. Guiding Session Strategy: Informing Technique and Focus

The form gathers specific data that directly shapes the session's application.

  • Areas of Pain/Discomfort: This tells the practitioner where to be especially mindful, potentially use lighter touch, or conversely, which reflex areas might require more attention based on corresponding body maps.
  • Areas to Avoid: This empowers the client to communicate personal comfort levels, fostering collaboration.
  • Lifestyle & Well-being: Stress levels, sleep, and hydration offer a holistic snapshot. This context helps the practitioner gauge the client's current state and can explain sensitivities or session outcomes, such as a client's heightened response due to stress or dehydration.

4. Establishing Clarity and Partnership

The final consent section is framed as a mutual agreement, not just a administrative step.

  • Clarity of Scope: It clearly defines reflexology as a complementary therapy for relaxation and well-being, distinct from medical diagnosis or treatment. This manages expectations and builds trust through transparency.
  • Affirmation of Honesty: The client's affirmation to provide accurate information reinforces a partnership based on open communication, which is essential for safety and efficacy.
  • Therapist's Notes Section: This is a crucial closing loop, allowing for personalized session observations, client responses, and plans for future sessions, making the form a living part of ongoing care.

Summary: The Form as a Dynamic Tool

This intake form template serves three interconnected purposes:

  1. A Safety Protocol: It systematically identifies factors to ensure the session is conducted appropriately for the individual's current health.
  2. A Clinical Guide: The information provides a map for the practitioner, suggesting where to apply techniques, how to modulate pressure, and what systemic effects to be aware of.
  3. A Relationship Charter: It initiates a collaborative dialogue, sets clear boundaries for the practice, and places the client's stated needs and comfort at the center of the process.

By collecting this information beforehand, the initial session time can be used more effectively for discussion and treatment, building a foundation for a supportive and professional therapeutic relationship.


Mandatory Questions Recommendation

Please remove this mandatory questions recommendation before publishing.

Mandatory Questions & Core Rationale:

1. Full Name & Date of Birth

  • Why Mandatory: This is the primary identifier for client records. Date of birth is crucial for differentiating between clients with similar names and is a standard demographic marker in health history.

2. Reason for Visit / Primary Goal

  • Why Mandatory: This defines the purpose of the session and aligns practitioner and client expectations. It directly informs the practitioner's approach—whether to focus on deep relaxation, work on reflexes related to a specific system, or apply general balancing techniques. It ensures the session is client-centered from the outset.

3. Medical History Checkboxes (Specifically: Heart/Circulatory conditions, Diabetes, Cancer, Epilepsy, Deep Vein Thrombosis (DVT) or Phlebitis, current Pregnancy)

  • Why Mandatory: These conditions carry significant implications for pressure, technique, and session planning.
    • Heart/Circulatory & Diabetes: Can affect sensation and circulation. Pressure must be carefully moderated, and areas of potential vascular compromise approached with caution.
    • Cancer (Current or in remission): Treatment can affect the body profoundly. The practitioner must be aware to adapt pressure, avoid areas affected by treatment (like lymph nodes), and understand the client's overall fragility.
    • Epilepsy: The practitioner must be prepared for the unlikely event of a seizure during deep relaxation.
    • DVT/Phlebitis: Absolute contra-indication for direct work on the affected limb. Applying pressure could dislodge a clot, which is a serious medical event.
    • Pregnancy: Reflexology techniques, especially in the first trimester, are adapted. Certain reflex points are avoided, and positioning for client comfort is paramount.

4. Current Medications

  • Why Mandatory: Medications reveal underlying conditions and can influence the session. For example, blood thinners increase the risk of bruising, requiring lighter pressure. Anti-hypertensives combined with relaxing reflexology can lower blood pressure further. This information is critical for safe pressure application.

5. Allergies (Specifically to topical agents)

  • Why Mandatory: To prevent a reaction. Many practitioners use lotions, oils, or cleansing wipes. Knowledge of allergies (e.g., to nuts, essential oils, latex, or aloe) is necessary to select safe products for contact with the client's skin.

6. Specific Area Focus: Current Pain, Injury, or Issues in the Feet, Ankles, or Legs.

  • Why Mandatory: This is the direct "workspace" assessment. Conditions like plantar warts, athlete's foot, gout flare-up, open wounds, recent surgery, or severe inflammation are often local contra-indications, meaning that area must be avoided entirely or worked around with extreme care. This protects the client from discomfort or harm and the practitioner from cross-contamination.

7. The Consent & Client Affirmation Statement

  • Why Mandatory: This section is not merely administrative. It ensures informed consent. The client confirms they understand the nature of reflexology as a complementary therapy (not medical treatment), affirms the accuracy of their disclosed health information, and agrees to participate. This establishes a clear professional boundary and a shared understanding, which is the bedrock of a trusting therapeutic relationship.


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