Please enable JavaScript in your browser to complete this form.1234Name *Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodeTelephone: Home *Telephone: WorkTelephone: MobileEmergency contect phone number *Email address *How did you hear about my facial reflexology treatments? *Date of birth *NextHeight *Weight *Stress level Selected Value: 0 1 is very relaxed, with no stress and 10 is highly stressed, where is begins to impact your sleep, mood etc.Lifestyle *Do you smoke? *YesNoHow many units of alcohol do you drink each week? *How many cups/glasses do you drink each day?Tea Selected Value: 0 Coffee Selected Value: 0 Water Selected Value: 0 Other fluids Selected Value: 0 Do you take any nutritional and herbal supplements? *YesNoPlease provide details of ones you take, how long you have been taking them and why. *Please provide details of any regular exercise you take part in:How well do you sleep each night? *NextMedical detailsGeneral health *Musculoskeletal System – Do you have any any problems with any of the below areas?Spine/BackOsteoporosisArthritisRheumatismTeethFrozen ShoulderRSITennis ElbowRespiratory System – Do you have any problems with any of the below areas?AllergiesAsthmaBreathlessnessBronchitisCoughs and ColdsEmphysemaSinusitisDermatological and Cosmetic – Do you have any problems with the below areas?DermatitisEczemaAllergiesCold SoresAcneBoilsPsoriasisRoseceaDry SkinHave you received any of the following?Face LiftFacial FillersBotoxPlease note: If you have received Botox or Facial Fillers, a treatment cannot go ahead following the three weeks from receiving it. If you have undergone Face Lift surgery, a treatment cannot go ahead until three months after the operation, and six months if there have been any complications/infections. If you have any questions about this, please email me at: kelly@kellyhainsworth.com.Cardiovascular System – Do you have any problems with the below areas?PalpitationsHeart ProblemsIrregular HeartbeatVaricose VeinsHigh Blood PressureLow Blood PressureCrampsCold Hands or FeetDizzinessFaintingHaemorrhoidsBlood pressure *Lymphatic System – Do you have any problems with the below areas?Tonsils/TonsillitisGlandsFluid Retention – swollen ankles, legs or handsCelluliteGastrointestinal System – Do you have any problems with the below areas?ConstipationDiarrhoeaIndigestionFlatulenceCoated TongueDry MouthIrritable Bowel SyndromeNervous System – Do you have any problems with the below areas? HeadachesMigrainesInsomniaDrowsinessExcessive SweatingMood SwingsEndocrine System – Do you have any problems with the below areas?ThyroidDiabetesUrogenital System – Do you have any problems with the below areas? KidneysCystitisFluid RetentionStress IncontinenceGynaecological System – Do you have any problems with the below areas? Irregular PeriodsLate PeriodsBloatingPMTCystsEndometriosisDo you have any recurring pains? *YesNoDetails of the recurring pain(s)Please provide details of any surgery you may have had *Please provide details of any injuries/accidents you may have had *Do you have any allergies? *YesNoPlease provide detailsNextAre you pregnant? *YesNoWhen is your due date?GP name and addressName of midwifeDetails of previous pregnancies and laboursHave you had or do you have any of the following?Recent vaginal bleeding *YesNoDVT (deep vein thrombosis) *YesNoPre-eclampisa *YesNoHistory of miscarriage *YesNoHydroamnios *YesNoIf you answered 'Yes' to any of the above conditions a treatment is not suitable to go ahead – please contact Kelly to discuss.I give permission for Facial Reflexology to be carried out and my Midwife gives full permission for the treatment to take place. *YesFamily medical history *Current medical treatment *Prescribed medication *What is your reason for receiving a facial reflexology treatment? *Disclaimer *I agreeTreatment I hereby confirm that all the information I have provided is a true and accurate reflection of my state of health. I agree to inform Kelly Hainsworth if any of the information changes throughout my course of treatments and accept this is my responsibility. I give permission for reflexology to be carried out. I have had the treatment explained to me and accept full responsibility. Parking Please note: Clients’ vehicles are parked entirely at their own risk. Kelly Hainsworth accepts no liability for loss or damage to vehicles or other possessions. Booking and cancellation policyWhen booking a reflexology appointment, please read and note the following cancellation policy. If you need to cancel or reschedule your reflexology appointment, the following cancellation policy fees apply: Treatments cancelled within 48 to 24 hours’ notice of the scheduled appointment will be charged a fee of 50% of the treatment price. Treatments cancelled within 24 hours’ notice or less of the scheduled appointment will be charged a fee of 100% of the treatment price. No show – Failure to attend the scheduled appointment will result in a fee of 100% of the treatment price being charged. Please note this cancellation policy also applies to bookings made when redeeming one of my treatment vouchers. If you are using a treatment voucher you can either pay the fee via bank transfer, or I can deduct the fee from your voucher total. All fees are to be paid via bank transfer to Kelly Hainsworth by the date of the missed appointment.Late arrival As a courtesy to all clients, a prompt appointment schedule is adhered to. Late arrivals will unfortunately not be guaranteed a full treatment time. A late arrival may also result in an appointment not being honoured and the full price of the treatment will apply. A data protection form will be handed to you at your treatment to read and sign. Look forward to meeting you soon, Kelly.Submit