REFLEXOLOGY HEALTH RECORD
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- Ann Moore
- 6 years ago
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1 REFLEXOLOGY HEALTH RECORD THIS FORM IS TO BE COMPLETED BY THE CLIENT FIRST THEN BY PRACTITIONER FOR INITIAL SESSION Client Date of Birth Telephone Home Business Ext Address Street # City Street Name Province Postal Code Doctor s Name Doctor s Address Telephone 1. What is your occupation? 2. Are you in good health? Yes No Explain: 3. Are you undergoing other therapies? Yes No List 4. What else are you doing for your health? 5. What are your goals/expectations for this session? 6. When did you last visit your doctor? Reason 7. List past surgeries and time of same: 8. List past injuries and time of same: 9. Are you taking medications? (Please include any vitamins or dietary supplements.) Yes No Reasons for taking: 10. Do you sleep well? Yes No Explain: Page 1 of 6
2 11. Do you suffer from anxiety or worry? Yes No Explain: 12. Is your blood pressure: Normal High Low Stable Erratic 13. Are you pregnant? Yes No If yes, which trimester? 1st 2nd 3rd 14. Have you had other pregnancies? Yes No 15. Do you have allergies/sinus conditions? Yes No List: 16. Do you have varicose veins? Yes No 17. Do you wear prostheses (e.g. glasses, contacts, glass eye, artificial joints/limbs, metal plates, pins, or wires, dentures, hearing aids?) Yes No Circle which one 18. Is there anything else about your health you wish to discuss? Yes No Explain: 19. Are you presently experiencing any of the following? Sunburn Inflammation Pain Headache Skin Rash Cold/Flu Cuts Bruises Burns Decreased Range of Motion Other: 20. Please indicate your consumption level of the following by placing an X in the appropriate column. None Light Moderate Heavy Salt Sugar Caffeine Tobacco Alcohol Exercise Water Consent to Receive Treatment I, the undersigned, consent to reflexology treatment and understand that sessions are for the purpose of stress reduction and relaxation. I may stop the session at anytime, either during the assessment or the treatment. Reflexologists do not diagnose, prescribe medication for medical or psychological conditions, nor treat for specific conditions. Signature: Date: Page 2 of 6
3 Do you have problems with any of the following systems? Endocrine System (diabetes, hypoglycemia, menopausal problems, hypothyroidism) Yes No Urinary System (kidney disease, urinary problems) Yes No Cardiovascular (high/low blood pressure, heart disease, phlebitis, varicose veins, Yes No circulation problems, anemia, etc.) Immune & Lymphatic (arthritis, chronic fatigue, environmental illness, HIV/AIDS, Yes No allergies, etc.) Musculoskeletal (osteoporosis, fibromyalgia, bursitis, gout, back pain, scoliosis Yes No foot, arm or hand problems) Respiratory (asthmas, emphysema, etc.) Yes No Nervous System (vision, hearing loss/problems, loss of sensation, Yes No nerve pain/damage, mental or emotional problems, MS) Reproductive (PMS, dysmenorrhea, endometriosis, prostate problems, etc.) Yes No Digestive (prolonged constipation, diarrhea, Crohn s Disease, Yes No Colitis, diverticulitis, ulcer, etc.) Integumentary (Skin) (Psoriasis, eczema, warts, etc.) Yes No Other Tuberculosis Yes No Cancer Yes No Aids Yes No Hepatitis Yes No Herpes Yes No If a client is experiencing pain, use the reminder phrase OL DR FICARA, when questioning the client to determine the following: Onset? Duration? Frequency? Character (dull, sharp, etc.)? Relieving Factors? Location? Radiation? Intensity? Aggravating Factors? Associated Symptoms? Page 3 of 6
4 REFLEXOLOGY INITIAL TREATMENT RECORD NOTE: A GLOSSARY OF SYMBOLS MUST ACCOMPANY THIS PAGE FOR REFERENCE Client: Date of Initial Session: Client Signature: Page 4 of 6
5 All questions to be completed for each session-use Notes page if needed Client Name and Client Signature: Session: Date: Felt Last Treatment Felt Since Treatment Feels Today Observations of Client Right Foot Observations Left Findings During Treatment Action Taken Results Clients Comments Final Observations Treatment Notes Page 5 of 6
6 For Health Record & Session Notes Page 6 of 6
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Laser Vein Center Thomas Wright MD Page 1 of 4
Demographics Laser Vein Center Thomas Wright MD Page 1 of 4 Patient Name: Address: City, St, Zip Primary Phone: Alternate: DOB: Social Security #: Insurance Information Primary Insurance ID# Group# Subscriber