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 Heartbeat Varicose 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 Retention Stress 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 policyPlease note 48 hours' notice via telephone is required for the cancellation or re-scheduling of an appointment otherwise a fee may be charged.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
