New Client Consultation Form | holistictherapist

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First name*

Last name

Email*

Address

Date of birth

Day

Month

Year

What has brought you to reflexology today?

What would you most like help with?

Medical Conditions

Anaemia

Anxiety

Arthritis

Asthma

Atrial Fibrillation (AF)

Autoimmune Condition

Blood Clots / DVT

Cancer (Past or Present)

Chronic Fatigue Syndrome / ME

COPD

Depression

Diabetes

Eczema / Psoriasis

Epilepsy

Fibromyalgia

Heart Condition

High Blood Pressure

High Cholesterol

IBS

Kidney Disease

Long COVID

Low Blood Pressure

Lymphoedema

Migraines

Multiple Sclerosis (MS)

Neuropathy

Osteoarthritis

Osteoporosis

Parkinson's Disease

Perimenopause / Menopause

Peripheral Vascular Disease (PVD)

Raynaud's Syndrome

Stroke / TIA

Thyroid Disorder

Varicose Veins

Vertigo / Balance Problems

Other (please specify)

Have you had reflexology before?

Yes

No

Current Medication (if applicable)

Allergies

Recent surgery or injuries - please specify

How would you rate your sleep

How would you rate your stress

How would you rate your energy

I confirm the information above is accurate to the best of my knowledge.

I consent to Andrea Nunnery Holistic Therapist storing my information securely in accordance with GDPR.

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