Reflexology intake form pdf

A referral from your primary care provider may be required prior to service being provided. Microsoft word gi patient intake questionnaire1 created date. Reflexologyenergy work waiver and consent form thank you for choosing natural wellness centre for your reflexologyenergy work therapy. If i have any medical condition that requires a physicians care, i have consulted himher regarding receiving a massagereflexology. An informed consent and waiver form should also be enclosed with the therapy intake form to assure that the. For detailed information on course and subject requirements, please see other. First time clients centralpenn central penn reflexology. A reflexologist is not a medical doctor, therefore does not diagnose, prescribe or treat for a specific condition. Keep track of your massage clients condition and progress with sample soap notes.

Hand reflexology session records order form 17 iii. She will also inform you that reflexology does not treat specific. Name phone day phone eve address citystatezip email date of birth occupation emergency contact phone the following information will be used to help plan safe and effective massage sessions. Another variety is an insurance patient intake form which is provided by the patients health insurance provider. This allows your body to relax and release tension and stress.

I understand that a massage therapist can not diagnose illness, disease, or any other medical, physical, or emotional disorder, nor perform any spinal manipulations. Rest assured that your information is confidential. Reflexology client intake form family chiropractic. Clients can sign off on the form electronically, making it easy to speed up the intake process and begin. The most common is a healthcare patient intake form which is used by doctors, nurses, and hospital staff. Our members get exclusive access to all the original files to fully customize however they please plus. A basic health form for informational background on you before proceeding with a reflexology session.

Reflexology reduces stress and brings about relaxation. Also known as client intake form, a massage intake form is a way by which therapists record patient contact information, specify policies, and get an idea of the patients issues, medications, and contraindications. Hand reflexology health and session records as part of the certification process for becoming a certified hand reflexologist, the student must complete the following practicum procedures as part. Stones are heated and used with oils to sooth, warm, and massage your muscles. Protect yourself, your clients and your massage therapy practice by utilizing proper documentation techniques. Healing powers reflexology intake form pdf download. Reflexology stimulates circulation and the delivery of oxygen and nutrients to the cells. Ganci so that the pressure and or strokes may be adjusted to my level of comfort. I have completed this form to the best of my ability and knowledge and agree to inform my reflexologist if any of the above information changes at any time.

Please answer the questions to the best of your knowledge. Massage and bodywork intake form client information name city state zip date day phone eve phone occupation date of birth emergency contact name and phone. The form has four sections namely the client information section, session information section, previous history section, and an acknowledgment section. Alle es asthma back pain cancer diabetes sciatica stress varicose veins arthritis bursitis.

May 07, 2019 international academy of reflexology and meridian therapy application 2020 pdf form, university of reflexology application requirements 20202021. I have stated all of my known medical conditions on the client intake form. If yes, please complete the billing information form. I understand that the massage bodywork i receive is provided for the basic purpose of relaxation and relief of muscular tension.

I understand that massage and reflexology are compliments to healthcare and not a substitute for medical. Welcome to healing powers reflexology 242 heritage park dr, suite 104, murfreesboro, tn 37129. Use amtas client intake forms to fully understand your client before you begin your first massage session. Heart problems drug dependence alcohol dependence caffeine dependence history of abuse.

This is the common type of massage intake form that can be provided to all massage clients. Personal information includes all the ilformation that you provided to us on our client information healthmedical history form at the first visit and any subsequent visits. I further understand that reflexology should not be construed as a substitute for medical examination, diagnosis or treatment and that i should see a physician, chiropractor or other qualified medical speciali st for any mental or physical ailment of. Please take a moment to read the following information. I understand that i may discontinue a session or sessions at any time. For the provision of professional reflexology health care services provided to you. Reflexology helps increase blood supply to the tissues and all parts of the body and stimulates the nerve impulses that aid in the bodys internal communication through helping the body relax and release tension. This is why reflexology can be a very effective technique for good health, preventing symptoms of stress and illnesses from surfacing. International academy of reflexology and meridian therapy application 2020 pdfform, university of reflexology application requirements 20202021. Client intake form reflexology personal information.

I have stated all my known medical conditions and take it upon myself to keep the reflexologist updated on my physical health. If you have just started practicing reflexology, it. Please answer questions to the best of your knowledge. The varieties of patient intake forms are only a few. University of reflexology 20202021 intake deadline is the day that the university of reflexology 202020212020 admission applications. By signing this form, i give my consent to a reflexology session. Reflexology is a type of massage that involves applying different amounts of pressure to the feet, hands, and ears. Our members get exclusive access to all the original files to fully customize however. Thank you for taking the first step in taking care of your health with reflexology. Reflexology health form awakened soles reflexology. Should you find you will be arriving a bit late for your appointment, the courtesy of. If i experience any pain or discomfort during this session, i will immediately inform the therapist lia digiacomo and or michael p. This is the reason why massage centers and sessions are available in order for people to have a quiet and stressfree time for themselves.

Contract for services by signing this form, i give my consent to a reflexology session. If you are a new client booking reflexology with robyn harding please fill out this reflexology intake form pdf. I understand that massage and reflexology are compliments to healthcare and not a substitute for medical supervision of any condition. The school or instructor must complete an arcb school verification form that states the program is a combined program that covers the required course and subject components and verifies the number of classroom instruction hours dedicated to hand reflexology. This form of practice is carried out using maps having predefined points located on your feet. Reflexology energy work waiver and consent form thank you for choosing natural wellness centre for your reflexology energy work therapy.

Balanced bodycare, pllc holly glennon rnbsn, lmt nationally certi. By signing this form, i certify that the above information is correct to the best of my knowledge. This has two sections mainly patient information and an agreement section. Client information form reflexology r don t hurt me. Oncology massage intake form must accompany a complete. It is our goal to provide you the most therapeutic experience possible. I understand that it is solely my responsibility to keep the therapist updated on any changes in my physical health and i. Reflexology client form under, do not resell or distribute these files. I may stop the session at any time, either during the assessment or the treatment. Online booking is not supported by microsoft edge or internet explorer. Client intake form reflexology holistic health and fitness. Each recorded reflexology session will be referred to as a reflexology session record, not a treatment or medical record. If you have to cancel your appointment, we ask that you do so 24 hours in advance. Phone occupation date of birth work age please circle he appropriate answers if you have had any of the following conditions.

Hot stone massage is often paired with swedish massage. Client intake form therapeutic massage personal information. In accordance with the law, massage therapybodywork cannot cure, treat, prevent or diagnose any condition. Reflexology promotes balance and normalization of the body naturally. We are pleased to keep you informed about university of reflexology 20202021 application requirements, university of reflexology online application 20202021, university of reflexology application form 20202021 pdf, admission requirements. Wellness center consent form i certify that the above information is correct to the best of my knowledge. Reflexology treatment consent and intake form form mobile. The reflexology session what can one expect usually, a session begins with a client health intake and interview. See more ideas about massage, massage intake forms and massage therapy.

Save time and get started right away on your first visit by filling out an intake form. If i have been diagnosed by a licensed health professional. Whether you are just researching or interested in making your first appointment, well walk you through every step of the way. I have completed this form to the best of my knowledge and will inform the massage therapist of any change in my physical health. Its based on a theory that these body parts are connected to specific organs and body systems. All the information in reflexology is valid and meaningful. Underline past conditions check here if explanation below. A separate form is required before receiving manual lymphatic drainage.

This easytocustomize client intake form for reflexology services covers all important client details, including reasons for seeking treatment, a brief medical history, existing medical conditions and medications, and contact details. Generally, therapists require patients to fill out the massage intake form before their appointment. Since the therapy intake form will gather the personal information of the client, it is significant that the therapist has acquired the clients legal consent to use all the statements and details that the client disclosed in the form. The reflexology component of the exam will involve questions about reflexes to work for specific conditions. There will be a charge of up to 75% of your appointment if you fail to cancel your. Sessions are scheduled with generous time for unhurried ease of transition between clients. I have consulted a medical doctor or licensed medical health care practitioner regarding any checked or described conditions. Even though reflexology is a form alternate medicine, it is based on years of scientific and medical research. Moreover, reflexology is an entirely different practice than that of massage. Free forms massage therapy business, massage marketing. Please mark c next to the currentchronic issues below and p next to those youve had in the past. The information on this page will walk you through.