Emergency Contact Number*

How did you hear about this service?*

Main reason for visit*

How long has this been a concern? (days, weeks, months, years)

Are you currently under the care of a doctor or practitioner?

How would you rate your current state of health?

The following information will be used to help plan safe and effective sessions. Please answer to the best of your knowledge and advise of any changes during or between sessions.

Nervous System; eyes, vision, hearing, loss of sensation, nerve pain or damage, sciatica, MS, brain, depression, anxiety, mental or emotional issues) (if yes, specify)

Endocrine System (Hormones): any conditions affecting the glands (adrenal, pituitary, pineal, hypothalamus, ovaries/testes, pancreas, thyroid, parathyroid) diabetes, hypoglycemia, hypothyroidism, menopause (if yes, specify)

Musculoskeletal System; muscle and or bone condition, joint pain, osteoporosis, arthritis, fibromyalgia, bursitis, gout, scoliosis, back pain (if yes, specify)

Immune and Lymphatic System; arthritis, allergies, chronic fatigue, environmental illness, HIV/AIDS, any autoimmune or inflammatory disease (if yes, specifiy)

Cardiovascular System;high or low blood pressure, heart disease, phlebitis, varicose veins, poor circulation, anemia (if yes, specify)

Respiratory System; Asthma, emphysema (if yes, specify)

Reproduction System;PMS, dysmenorrheal, endometriosis, prostate problems, infertility (if yes, specify)

Urinary System; kidney disease, urinary issues (if yes, specify)

Digestive System;IBS, crohn's disease, colitis, diverticulitis, ulcer, heartburn, indigestion, bowel movements (if yes, specify)

Integumentary System (skin, scalp, nails); psoriasis, eczema, warts, scars(if yes, specify)

Allergies;example; food, environmental, animals, peanuts, tree nuts (if yes, specify)

Medications (prescribed, supplements, natural alternatives)

Sleep (hours/night) and Quality

Do you feel rested upon waking?

Energy Level (1 low, 5 high)

How many glasses of water are you drinking each day

Rate Tension and Stress (1 low, 5 high)

Lifestyle/Addictions; smoking, vaping, drugs, alcohols, eating behaviors, behavioral

Thrombosis (blood clots) *(contraindication)*

Diabetes/Hypoglycemia

Pregnancy, if yes what trimester

Local or structural conditions of the hand/foot

How do you feel about emotional expression and balance?

Headaches or migraines? If yes, frequency, duration, what triggers them, how do you manage them?

Accuracy of Information; I certify that the above medical information is correct to my knowledge. *

Privacy; I authorize the clinic and its associated health professionals to collect my personal and medical information as documented above. I understand that my personal and medical information is confidential and will only be disclosed to third parties with my permission. *

Cancellation Policy; Your appointment time is reserved just for you. We require 24 hours notice for any cancellations or changes to your appointment. Patients who provide less than 24 hours notice, or miss their appointment will be charged a cancellation fee. *

Informed Consent with Haley Lorman, Certified Reflexologist; I will inform Haley if I do not understand any given part of my treatment or if I am uncomfortable with any aspect of my care. All information I provide Haley is confidential unless required by law. My case information may be used for the publication of case reports or case studies. My identity will be excluded to maintain anonymity*

Virtual Signature; By typing your name below, you acknowledge that you are virtually signing this document and that all information is correct to the best of your ability. *