Health History Form

First Name

Last Name

Date of Birth

Occupation

Street Address

City

Province

Postal Code

Cell Phone Number

Work Phone

Preferred Contact Method

Phone

Text

Emergency Contact

Relationship

Phone#

Family Doctor

Please indicate conditions you are currently experiencing or have experienced in the past.

Cardiovascular

High Blood Pressure

Low Blood Pressure

Heart Attack

Phlebitis

Stroke

Pulmonary Emboli

Pacemaker/defibrillator

Heart Disease

Swelling of Ankles

Infectious Disease

Hepatitis

Infectious Skin

Tuberculosis

HIV

Face/Head/Neck

Tooth/Jaw/Ear pain or TMJ

Vision Loss

Hearing Loss

Head Trauma

Headaches

Other Infections

Foot Condition

Current Medications./ Drugs - Reason for medications Drugs

I have read the above information and have stated all my previous and current medical conditions. I take it upon myself to update the therapist regarding any changes in my condition. I understand that all Foot reflexology, Facial reflexology, Indian Head Massage, Therapeutic Touch or Reiki will be discussed and planned with the therapist and will require informed consent. I understand the 24 hrs cancellation policy and agree to pay the missed appointments within 24 hours of my appointment time.

Consent

Yes

Signature

Clear

Date

Suzanne's Foot Reflexology Care

Services

Office

Hours

Info

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