🌿 Client Intake Form 

Confidential Client Information

Please complete this form carefully. Your information is confidential and used to tailor your reflexology treatment.

1. Personal Information

  • Full Name:

  • Preferred Name/Nickname:

  • Date of Birth (DD/MM/YYYY):

  • Age:

  • Gender:

  • Phone Number (Mobile/Home):

  • Email Address:

  • Home Address:

  • Occupation:

  • Emergency Contact Name & Phone Number:

  • How did you hear about us? (Referral, Website, Social Media, Walk-in, etc.)

2. Medical History

Please check all that apply or write details where needed.

General Health

  • Excellent

  • Good

  • Fair

  • Poor

Primary Health Concerns or Reasons for Visit:

(Please describe the main issue or goal for your reflexology session.)

Current Medical Conditions:

  • Diabetes (Type I / II)

  • High Blood Pressure

  • Low Blood Pressure

  • Heart Condition

  • Thyroid Imbalance

  • Arthritis

  • Neuropathy

  • Epilepsy or Seizures

  • Fibromyalgia

  • Digestive Issues

  • Respiratory Conditions (Asthma, COPD, etc.)

  • Chronic Fatigue Syndrome

  • Circulatory Issues

  • Depression / Anxiety / Mental Health Disorders

  • Insomnia or Sleep Disorders

  • Cancer (Current or Past)

  • Other: _________________________________

Past Surgeries or Hospitalizations:

Are you currently pregnant?

  • Yes (Weeks: ___)

  • No

  • Possibly

Medications (prescription or over-the-counter):

Supplements / Herbal Remedies:

Allergies (including lotions, oils, scents):

Skin Conditions (eczema, athlete’s foot, etc.):

3. Lifestyle & Wellness Profile

Activity Level

  • Sedentary

  • Light Activity

  • Moderately Active

  • Very Active

Sleep

  • Average hours per night: ______

  • Restful

  • Disturbed

  • Insomnia

Stress Level

  • Low

  • Moderate

  • High

  • Primary sources of stress: ___________________

Diet

  • Healthy/Balanced

  • Fast Food Often

  • Vegetarian/Vegan

  • Food Sensitivities (please list): ___________

Water Intake

  • Average glasses per day: _______

Alcohol Consumption

  • None

  • Occasionally

  • Regularly

Smoking

  • No

  • Yes (Amount: ___/day)

  • Previously (When quit: ______)

4. Reflexology Experience & Preferences

Have you had reflexology before?

  • Yes

  • No

If yes, how often? ________
Last session? ___________

Are you currently receiving any other therapies?

  • Massage

  • Acupuncture

  • Physiotherapy

  • Chiropractic

  • Naturopathic

  • Psychotherapy

  • Energy Healing

  • Other: ___________________

What are your primary goals for reflexology?

(check all that apply)

  • General Relaxation

  • Stress Reduction

  • Pain Relief (specify location: ____________)

  • Improved Circulation

  • Better Sleep

  • Digestion Support

  • Hormonal Balance

  • Boost Energy

  • Specific condition support (describe): ________

Do you have any specific areas of concern on your feet?

  • Heels

  • Arches

  • Toes

  • Ankles

  • Ball of foot

  • Skin Conditions (corns, calluses, etc.)
    Details: ___________________________________________

Are you ticklish on your feet?

  • Not at all

  • Slightly

  • Very

Are there areas on your feet you would prefer not to be touched?

5. Consent & Disclosure

  • I understand that reflexology is a complementary therapy and is not a substitute for medical care.

  • I will inform the reflexologist of any changes in my health.

  • I give my informed consent for reflexology treatment.

  • I understand that treatment may be refused or adjusted if contraindicated by a health condition.

Name: _______________________  Date: ________________

Optional Feedback

What would make this a great experience for you today?

Do you have any concerns or expectations you’d like to share?

Would you like to be contacted for follow-up or promotions?

  • Yes

  • No
    Preferred method: [ ] Email [ ] Phone [ ] Text

 

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