Reflexology In Pregnancy Treatment Form

First name

Last name

Email

Phone

Address

Conditions and/ or symptoms (contraindications to the treatment)

Swelling/oedema

Mental Health Condition

Phlebitis

Unstable blood pressure

Heart disorders

History of thrombosis/embolism

Epilepsy

Infectious diseases

Skin disorders

Recent scar tissue

Haemorrhage

Varicose Veins

Recently had any operations?

Have you ever had or do have cancer?

Back problems

Recent fractures or sprains

Currently suffering from a fever, diarrhoea or vomiting?

Diabetes

Osteporosis

Arthritis

Allergies

Asthmatic conditions

Is a doctor/ complementary practitioner treating you for any condition?

If you have ticked any of the options above please explain further

Do you have any medically diagnosed conditions? If so please give details

Please give details of any medication you are taking

How many weeks pregnant are you?

Do you have any of the following conditions?

Placenta Previa

Hydramnios/ Oligohydramios/ Polyhydramios

Pre-eclampsia or HELLP Syndrome

Gestational Diabetes

If you've been pregnant before, have you had a previous pre-term labour (between 20 and 37 weeks)

If you have ticked and of the options above please explain further

Are there any complications or conditions you've been having during your pregnancy that you would like me to be aware of?

Do you suffer with any issues in the following areas? Tick if/ where appropriate and we'll discuss further during your consultation in person

Back pain, aches/pains

Stiff joints

Headaches

Migraines

Stress/Anxiety/depression

Digestive issues: bloating/constipation/stomach/liver or gallbladder

Immune system: Sinuses/regular colds/chest issues/prone to infections

Circulation problems: kidney/blood pressure/fluid retention/varicose veins

Is there anything else that you would like me to know?

PRIVACY POLICY

GDPR (implemented by DPA2018 in the UK) brought in new legal protection for personal information from May 2018. This tells you what personal information I hold and why, and what your rights are.

The privacy policy can be found here.

By checking this box you are confirming that you have read the privacy policy at the above web address and understand that I will hold and use your personal information, using it in order to provide you with the best possible treatment options and advice in line with the statements mentioned in the policy.

CLIENT DECLARATION

By submitting this form I declare that the information I have given is true and correct. I am not aware of an underlying condition that would prevent me from undertaking treatments or may cause adverse effects to the treatment described.

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Reflexology In Pregnancy Treatment Form

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