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Medical Questionnaire

This form is mandatory and must be submitted prior to your first appointment. Without this information, we cannot proceed with your appointment. 


Do you consider yourself exposed to stressful situations?
Do you consider yourself to have healthy diet?
Do you drink alcohol?
Do you take any vitamin / protein supplemets or herbal remedies?
Do you have any allergies?
Do you smoke or vape?

Mind & Body

Do you suffer from: (tick all that apply)


Please select any of the options below which apply to you

If you are having Reflexology, it is important to know that it may not recommended for persons suffering from the following conditions: Thrombosis, phlebitis, gangrene, unstable heart condition, or any contagious disease.

I declare that all information given on this consultation form is, in all respects, complete, true and correct to the best of my knowledge. I also understand that if dietary supplements or homeopathic medicines are recommended, they are not being prescribed, and are being taken at my own risk. I understand and consent to undergo treatments, based on the explanation I have received and the medical information I have provided above.

Thanks for submitting!

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