Holistic Treatment Client Consultation Form

Date: _________________________________________________________________

Name: ________________________________________________________________

Address: ______________________________________________________________

Phone # / E-mail: _______________________________________________________

D.O.B: ________________________________________________________________

Please complete the following questions. Please be assured that the information that you give iscompletely confidential and held in accordance with Data Protection Legislation. All information gathered is used to inform and safeguard the therapy you receive.

Reflexology is a holistic therapy. Through the application of steady, even pressure using specificthumb and finger techniques, reflexology connects with the peripheral nervous system and encourages the body to relax. Feet mirror the body and each reflex point connects with a specific organ, gland, body part, or body system.

Current Health Issues:

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Aspirations for the treatment? / What outcome are you seeking for this visit?

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Occupation: __________________________________________________________________

Lifestyle (exercise, activities, diet, vitamins, etc.): ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Other forms of Holistic Healing / Bodywork: _________________________________________

Are you under stress? Rate 1-5 (5 high stress) At work? __________ At home? ___________

Do you have headaches? Yes / No How often?_____ Relieving factors?_______________

Do you sleep well? Yes / No Problems falling asleep? Once asleep, waking? How often? Do you wake feeling rested? ____________________________________________________________________________

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Holistic Treatment Client Consultation Form

Medical History

Are you currently under medical supervision yes / no

Details:________________________________________________________________

Are you currently on any medication? yes / no

If yes, are there any side effects I need to be aware of?__________________________

Are you currently pregnant? yes / no

Do you have menstrual / menopausal problems? Explain: _________________ yes / no

Are you living with any of the following conditions?

Epilepsy / Diabetes / Drug or Alcohol Dependency / Allergies / Low Blood Pressure

Do you have any joint problems? (Arthritis, etc.) Where? __________________ yes / no

How is your spine? (neck / mid back / low back) _______________________________

Do you have any foot problems / concerns? Explain: ____________________________

Any current tender spots on your feet? Explain: ________________________________

Are you aware of any other condition that may affect your treatment? yes / noIf yes, please comment: __________________________________________________

To the best of my knowledge the above information is correct and I am okay with being gently touched appropriately by the practioner during the treatment. I understand that this holistic treatment is a stress reduction and relaxation technique that may overcome or ease a broad range of ailments, disorders, or pain. I acknowledge that sessions administered are only for the purpose of helping me relax, relieve stress, and release blocked energy. I understand that Holistic Therapists do not diagnose conditions, nor do they prescribe substances or perform medical treatment, or interfere with the treatment of a licensed health care professional. It is recommended that I see a licensed physician, or licensed health care professional for any physical or psychological ailment or condition I may have.

I also understand that the body has the ability to heal itself, and to do so complete relaxation is often beneficial. Long-term imbalances in the body require multiple sessions to allow the body toreach the level of relaxation necessary to bring the system back into balance. I understand and believe that self-improvement requires commitment on my part, and that I must be willing to change in a positive way if I am to receive the full benefit of Holistic Therapy.

Signed: ___________________________________ Dated: __________________________

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Holistic Treatment Client Consultation Form

Client Aftercare Information:

It is important that following your treatment you drink plenty of water and take care to follow any of the specific instructions your therapist has given you.

Some people have an abundance of energy after a treatment while others may feel lethargic. Both feeling are perfectly normal. In extreme cases the treatment has caused a significant shift to a blockage and may result in an increase in urination or bowel movements – again, this is perfectly normal and in fact, a good indication that the therapy is working. However, if you do not experience this, it doesn’t mean to say that the treatment has not been effective, as everyone will respond differently. Allow yourself to relax and take time for yourself if at all possible. It is important to contact your therapist and doctor immediately should you feel any unusual sensations you are worried about. Your therapist is not a doctor and does not diagnose so it is important to get the advice of your doctor regarding medical questions.

Most of all, allow yourself to enjoy the wonderful benefits that your therapy will bring. Behappy knowing that you are taking steps to better your health and improve your quality of life.

Research has proven that the following advice helps to improve health and well-being:

Drink plenty of water Regular meditation Regular exercise Avoidance of alcohol (particularly before and after a treatment) Avoidance of caffeine e/g tea/coffee. Herbal teas are a good alternative If a smoker, try to reduce the number of cigarettes you smoke Eat light regular meals with plenty of fruit and vegetables Make quality time for yourself for rest and relaxation

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