Sacred Earth Healing Arts
Reflexology Medical History Forms
Reflexology Health Record Date:_____________
Name:_____________________________________ Date of Birth______________________
Address:_____________________________________________________
City:_____________________________ Province_____ Postal Code_______________
Email:___________________________________________________
Phone Number (H) ___________ (W) ___________________(C) _________________
1. What is your occupation?
_______________________________________________________________
2. Are you in good health? Yes No
Explain:_______________________________________________________
3. Are you undergoing other therapies? Yes No If yes,
list:__________________________________________
4. What else are you doing for your health?
___________________________________________________________
5. What are your objectives/expectations for this session?
_______________________________________________
6. When did you last visit your doctor?
_______________________________________________________________
Reason:__________________________________________________________
7. List past surgeries/injuries and when they occurred:
________________________________________________________
8. Are you taking medications? (Include vitamins & dietary supplements) Yes No If yes,
list:______________________________________________________________
9. Do you sleep well? Yes No If no,
explain:_______________________________________________________
10. Do you suffer from anxiety or worry? Yes No
Explain:____________________________________________
11. Is your blood pressure: Normal High Low Stable Erratic
Explain:_____________________________
12. Are you pregnant? Yes No
If yes, which trimester?_______________________________________________
a. Have you had other pregnancies? Yes No
If yes, was there complications? _______________________
13. Do you have allergies/sinus conditions? Yes No If yes,
explain:_____________________________________
14. Do you wear prostheses? (eg. Glasses, contacts, glass eye, artificial joint/limb, metal plate, pins or
wires, dentures, hearing aid) Yes No If yes,
list:_________________________________________________
15. Are there any current problems with your health?
Explain:______________________________________________
16. Is there anything else about your health you wish to discuss?
__________________________________________
________________________________________________________________
Consent: I, the undersigned, consent to reflexology treatment and understand that the sessions are for the purpose of stress reduction and relaxation. Reflexology does not substitute for medical examination, diagnosis, or treatment and I will consult a physician, or other qualified medical specialist for all my mental or physical ailment’s in which I am aware. I may stop the session at any time, either
during the assessment or the treatment. Reflexology Therapists do not diagnose, prescribe, treat for specific conditions or use tools of any kind. I confirm that I have informed the therapist of all my known medical conditions and answered all questions honestly. Should I seek further Reflexology treatment from the therapist I agree to update them as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part should I forget to do so.
Signature:___________________________________________________
Date: ____________________________
Are you presently experiencing any of the following?
Sunburn Inflammation
Pain Headache Skin rash
Cuts,
Bruises,
Burns
Colds/Flu
Decreased range of motion
Other _________________________
Please indicate your consumption level of the following:
NONE LIGHT MODERATE HEAVY
Salt Sugar
Caffeine
Tobacco
Alcohol
Exercise
Water
Cannabis
Circle the appropriate answer:
ENDOCRINE SYSTEM:
Diabetes Yes No Past
Hypoglycemia Yes No Past
Menopausal Problems Yes No Past
Hypothyroidism Yes No Past
Hyperthyroidism Yes No Past
Specify:
URINARY SYSTEM:
Kidney Disease Yes No Past
Kidney Stones Yes No Past
Urinary Problems Yes No Past
Specify:
CARDIOVASCULAR:
Heart Disease Yes No Past
Phlebitis Yes No Past
Varicose Veins Yes No Past
Circulation Problems Yes No Past
Anemia Yes No Past
Specify:
IMMUNE & LYMPHATIC:
Arthritis Yes No Past
Chronic Fatigue Yes No Past
HIV/AIDS Yes No Past
Specify:
MUSCULOSKELETAL:
Osteoporosis Yes No Past
Fibromyalgia Yes No Past
Bursitis Yes No Past
Gout Yes No Past
Back Pain Yes No Past
Scoliosis Yes No Past
Foot/Arm/Hand Problem Yes No Past
Specify:
RESPIRATORY:
Asthma Yes No Past
COPD Yes No Past
Emphysema Yes No Past
Tuberculosis Yes No Past
Specify:
NERVOUS:
Vision Yes No Past
Hearing loss/Problems Yes No Past
Nerve pain/Damage Yes No Past
Mental/Emotional Illness Yes No Past
MS Yes No Past
Specify:
REPRODUCTIVE:
PMS Yes No Past
Endometriosis Yes No Past
Prostate Problems Yes No Past
Specify:
DIGESTIVE:
Constipation Yes No Past
Diarrhea Yes No Past
Crohn’s Disease Yes No Past
Colitis Yes No Past
Diverticulitis Yes No Past
Ulcer Yes No Past
Specify:
INTEGUMENTARY (SKIN):
Psoriasis Yes No Past
Eczema Yes No Past
Warts Yes No Past
Specify:
OTHER:
Hepatitis Yes No Past
Herpes Yes No Past
Cancer Yes No Past
