Name *

First Name

Last Name

Date

MM

DD

YYYY

Phone *

(###)

###

####

Have you had an holistic therapy before *

Yes

No

What other therapies have you tried? *

Reflexology

Reiki

Meditation

Mindfulness

Yoga

Tai Chi

Herbal Medicine/Remedies

Acupuncture/Acupressure

Breathwork

Music therapy/Sound Bath

Counselling/Talking Therapy

Others

Medical History *

High/Low Blood pressure

Swelling/Oedema

Mental Health Conditions

Heart Disease

Epilepsy

Varicose Veins

Cancer - Past/Current

Back/Spinal Issues

Diabetes

Asthmatic Conditions

Recent Surgeries

Any other medical condition

Are you taking any prescribed medications? *

Yes

No

Are you taking any holistic medications? *

Not prescribed by your GP

Yes

No

Do you smoke? *

Yes

No

Do you Drink Alcohol *

Yes

No

Do you Exercise? *

Yes

No

What is the reasons why you want to have reflexology today? *

Relaxation/Stress reduction

Pain Management

Problems sleeping

Anxiety

Back problems

Migraines

Boost Circulation

Digestion

Increase Wellbeing

Swelling/Fluid/Oedema

Recent Surgery

I declare the information that I have given is true and correct and that as far as I’m aware, I can undertake treatment with The Happy Mind Studio - Fermanagh & James Graydon-Rhodes without any adverse effects. I understand that reflexology is not a substitute for medical advice and/or treatment and I will consult with my own GP should I have any concerns regarding my health. *

Yes

No

GDPR Compliance - Your personal data will be stored and be accessible by The Happy Mind Studio - Fermanagh & James Graydon-Rhodes. Your information will not be shared to any third party companies. We will only contact you with regards to The Happy Mind Studio & James Graydon-Rhodes and associated matters and will never send spam to you. MEDICAL MALPRACTICE : Your details will be kept on record for 3 years once you have received your last treatment with The Happy Mind Studio - Fermanagh & James Graydon-Rhodes. RECORD KEEPING Your consultation forms are kept on file on a password protected computer and paper files are kept in a locked filing cabinet at our business address. Your files are not viewed or accessible by anyone other than James Graydon-Rhodes of The Happy Mind Studio - Fermanagh, unless consent is given by yourself to share with other therapists. Medical Information Required The medical & emotional questions are required so that The Happy Mind Studio & James Graydon-Rhodes can provide a suitable & bespoke holistic treatment for you *

Yes

No

I authorise The Happy Mind Studio - Fermanagh & James Graydon-Rhodes to use any relevant photographs of my treatment (This will not include your face or personal details) *

Yes

No