General Questionnaire
CONFIDENTIAL QUESTIONNAIRE
HAVEN CLINICAL REFLEXOLOGY
A safe haven for your mind, your body, your 'sole'.
https://havenreflexology.wixsite.com/haven
0781 773 2962
Date: ………………………………................................. ... Reference: ………….
General Information:
Name: …………………………………………………………………………………………….
Address: ..........................................................................................................
Age: …………………………………
Date of birth: …………………………………
Telephone number: …………………………………………………………………………………………….
Email: …………………………………………………………………………………………...
Preferred method of contact: Telephone. Mobile. Email. (Please circle)
Emergency contact: ………………………………… Relationship to you: ……………………
Occupation: ……………………………………………………………………………………………
If yes, how many hours per week do you work? ………………………………………………………
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Specific Health Issues:
Do you have any allergies? Yes/No
If yes, what are you allergic to? ……………………………………………………………………………......
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Do you have a deep vein thrombosis (DVT)? Yes/No
Do you have diabetes? Yes/No. If yes, is it type II or type I?
Is your diabetes managed by diet only? Yes/No.
Do you take medication for it? Yes/No. If yes, what medication do you take?
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Do you have Athlete’s foot or any other contagious foot infection? Yes/No
Do you have any contagious conditions at the moment? Yes/No
If yes, please give details: …………………………………………………………………………..................
Are you due to have any medical treatments or surgery in the next 48 hours? Yes/No
Have you had surgery or hospital treatment in the last 48 hours? Yes/No
If yes, what are these please? ………………………………………………………………………………….
Do you currently have shingles? Yes/No
Do you currently have gout? Yes/No
Do you have severe varicose veins? Yes/No.
Do you use a nebulizer or an inhaler? Yes/No ………………………………………….................
If yes, why do you need to use them? ………………………………………………………..................
Have you had any operations in the past? Yes/No.
If yes, what were they? ………………………………………………………………………………………………
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Do you have any current medical conditions: Yes/No.
If yes, what are they: ………………………………………………………………………………………………….
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Are you taking any medications? Yes/No.
If yes, what are they? …………………………………………………………………………………………………
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Lifestyle:
Do you smoke: yes/no.
If yes, how many cigarettes do you smoke per day? ………………………………………………
Do you drink alcohol? Yes/No.
If yes, generally, how much do you drink per week? ………………………………………………
If yes: Very occasionally. On social occasions. Every weekend. More than 3 days a week.
Every day. (Please circle).
Do you take recreational drugs? Yes/No.
If yes, how much and how often? ………………………………………………………………………………
Generally, how many hours sleep do you have per night? ………………………………………
How much water/other do you drink per day? …………………………………………………………
What is your diet like? Very healthy. Average. Poor. (Please circle).
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Do you eat fruit and vegetables regularly? Never. Sometimes. Often. Every day. (Please circle)
Do you take time to relax?
If yes, what do you do? ……………………………………………………………………………………………….
Do you exercise regularly? Yes/No.
If yes, is it: Once in a while. Once a week. Twice a week. Three or more times a week.
(Please circle).
If yes, what do you do? ………………………………………………………………………………………………
Do you suffer from stress or anxiety? Yes/No.
Marking from 1-10; where would you say your stress levels are at the moment? (Please circle)
Stress: Good: 1—2--3--4--5—6--7--8--9—10. Bad.
If bad, is there a reason for your high score?
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Home: Good: 1--2--3--4--5--6--7—8—9--10. Bad.
Work: Good: 1--2—3--4--5--6--7—8—9--10. Bad.
How are your energy levels?
Energy: Good: 1—2—3—4—5—6—7—8--9--10. Bad.
If bad, is there a reason for the high score? ………………………………………………………….
WOMEN OF CHILD-BEARING YEARS:
Are you or, could you be, pregnant/in the 1st trimester? Yes/No.
Are your periods regular? Yes/No.
Do you suffer with premenstrual tension or other cyclical issues? Yes/No.
Post child-bearing years: Are you pre-menopausal or menopausal? Yes/No.
How do you feel about your feet? What do you like or dislike about them?
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Why have you decided to have reflexology?
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Clinical reflexology is a complementary therapy. It is very relaxing. However, it is much more than that. It has a very positive effect on the mind and body. Over time, it will encourage the body to unblock any imbalances and allow it to return to optimum health.
As a clinical reflexologist, I am able to offer guidance. However, I will never diagnose a condition nor prescribe medication for you. Although reflexology helps to alleviate many conditions, it cannot be said to cure.
It is important for you to drink a little water after your treatment. You may need to rest for a while afterwards.
Please sign below to confirm that you have read and understood the above, and that the information you have provided is correct. Thank you.
HAVEN complies by the General Data Protection Policy. You may view this via https://havenreflexology.wixsite.com/general-data-protection-policy.
I may, from time-to-time, email or text you with special offers that you may find useful. You may, of-course, decline or opt out at any time.
I hope you enjoy your reflexology treatment!
Client statement: I confirm that the information I have provided is correct as of today’s date.
Client’s signature: ……………………………………………………………………………........................
Reflexology Practitioner’s signature: …………………………………………………....................