Reflexology Health Record

Please fill out and submit before your first Reflexology session with Susan.

A complete health history helps us ensure it is safe to provide you with a reflexology treatment; please let us know if your status changes so we can update your form. All information given to us is confidential.

First Name^*

Last Name^*

Today's Date^*

Email^*

Phone Number^*

Business Phone

Address

Address Line 1 ^*

Address Line 2

City ^*

State or Region ^*

Zip

Age^*

Birth Date^*

Occupation

How did you hear about us?^*

Doctor's Name

Doctor's Phone

Last Check-Up Date

Have you had a reflexology treatment before?^*

If yes, approximate date of last reflexology treatment

Previous Major Illnesses / Operations (include dates)

Other Serious Medical Conditions

Allergies / Hypersensitivities

Major Accidents (include dates)

Have you been hospitalized recently?^*

Why / When?

Have you had any broken bones?^*

What / When?

Have you had any surgery?^*

What / When?

What is the main reason you would like reflexology?^*

Health History (please check all that apply to you)

Lifestyle (check all that apply)

Do you smoke?^*

No
Yes, What / How much?

Do You drink alcohol?^*

No
Yes, How much/ how often

What is your general health?

Service Agreement

Consent for Reflexology Session^*

I attest that the information I have provided is true and complete to the best of my knowledge.

I understand the information I have provided on this form is confidential and will not be released without my written consent.

I understand that Susan Lilley the Reflexologist can end the treatment at anytime due to inappropriate behaviour.

I understand and accept that the sessions received are of therapeutic value only and fully accept responsibility for the same.

I understand that Susan Lilley's services are designed to be a health aid and are in no way to take the place of a doctor's care when it is indicated. Information exchanged during any session is educational in nature and is intended to help me become more familiar and conscious of my own health status, and is to be used at my own discretion.

I understand that Susan Lilley does not diagnose or treat illness or injuries, and that I am solely responsible for my physical and psychological wellness and for seeking medical treatment when I feel it is necessary for my wellbeing. Susan Lilley shall not be held liable for choices that I make in this regard.

I give Susan Lilley permission to do Reflexology, Reiki, Hot Stone Therapy Massage, Yoga, Rapid Transformational Therapy, Coaching and any other services or therapies she may provide.

I understand 24 hours notice is required to reschedule all future appointments, or full charges will apply.

I have read and agree to Terms of Service and Privacy Policy found at www.livefullyandfreely.com

By checking the box I give consent.

I understand and Agree