Health Declaration/Reflexology

Please complete this form at least 24 hours prior to any Integrative Reflexology,TCM Dermatological or Facial Reflexology/Zone Face Lift appointments.

First Name

Last Name

Date of Birth

Phone #

Occupation

Medical History - (illnesses, diseases, disorders, accidents, injuries, surgeries, etc.

Current Medication

Have you been hospitalized in the last 12 months?

Yes

Are you suffering from a medical condition, illness, or injury?

Yes

Tell me. What are you want to accomplish at your session and how can I help you? ie. Pain Releif, Stress Relief, Muscular, Respiratory, Cardiovascular, Lymphatic, Gastrointestinal, Nervous System, Urogenital, Edrocrine, Gynaecological, etc.

What are your presenting conditions or areas of concern you want to address?

Typical Daily water intake

Exercise?

Smoke/Alcohol Consumption

Current Stress level

Have you had Botox, a Face Lift or a Facial Fillers within the past 4 weeks?

Yes

Do you have Allergies to anly nut based products or essential oils?

Yes

Do you currently have any open sores on feet or face or extreme acne on face?

Yes

Are you currently pregnant?

Yes

If you answered "YES" to any of the above questions, elaborate on procedures, allergies, open sores or stage in pregnancy or any pregnancy problems

I declare that the info I’ve provided is accurate & complete

Initials

Thanks for submitting!

Sandy Harrison

704.608.6164 | Sandy@SootheTheSoles.com

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