Consultation Form

If you ticked yes to any of the above please give details and list any medication you are currently taking:

Do you have any areas of pain at present?

How is your diet in general? Please include what you drink in a day on average and if you drink alcohol how often do you drink alcohol and how much:

Do you exercise and if so please describe what activities you do:

Do you find it easy to relax and sleep? (please provide details along with sleep pattern)

Please use this section to include and other relevant information including reasons for seeking reflexology:

Personal Details