Intake Form — Mindful Balance | Reflexology by Tom

01 · About you

A little about you

So I know who I’m welcoming, and how to reach you.

Full name *

Preferred name *

Date of birth *

Occupation

Home address *

Landline

Mobile number *

Email *

Emergency contact name

Emergency contact number

GP name & surgery *

Are you currently under the care of a doctor or specialist? *

No Yes

02 · Why you’re here

What brings you to reflexology?

In your own words, there are no wrong answers. This helps me shape your session.

What would you like help with? *

What would you like to get from your sessions? *

How would you rate your energy levels at the moment? *

1 = very low · 10 = very high

How would you rate your stress levels at the moment? *

1 = very calm · 10 = very stressed

Have you had reflexology or other complementary therapies before? *

03 · Your health

Medical history

Please tell me about anything relevant. If you’re unsure whether something matters, include it, as it’s always better that I know.

Illnesses, conditions, operations, accidents or injuries *

With rough dates where you can. If none, please write ‘None’.

Any relevant family medical history? *

Any upcoming medical tests or procedures, or recent surgery? *

If you’ve had recent surgery, please note whether you’ve been medically cleared for treatment.

Do any of these apply to you? Please tick all that are relevant.

These don’t necessarily prevent treatment. Some simply mean I’ll check with you, or ask you to speak with your GP first.

04 · Current wellbeing

How are things right now?

A quick picture of your general health today. Tick anything you currently experience.

Are you pregnant, or is there any possibility you could be? *

No Possibly Yes

Date of last period (if applicable)

Do you have any allergies? *

Including latex, plasters, oils, lotions, balms, nuts or scents I should avoid.

Anything affecting your feet, lower legs, hands, arms, neck, face or head at the moment? *

e.g. cuts, bruises, swelling, skin conditions, varicose veins or a recent injury.

05 · Medication & lifestyle

Medication & everyday life

The fuller the picture, the better I can tailor your treatment.

Current medication *

Prescribed and over-the-counter, including what it’s for. If none, please write ‘None’.

Any supplements, vitamins or herbal remedies? *

How is your diet, generally? *

Sleep *

Good Average Poor

Ability to relax *

Good Moderate Poor

How often do you exercise? *

None Occasionally Regularly

Do you smoke? *

No Yes

Alcohol *

None Light Moderate Heavy

Water (glasses/day) *

Caffeine (cups a day) *

Hours a day at a screen or desk? *

Any other relevant information?

06 · Consent & privacy

Your consent

Please read and confirm before we finish. This keeps you safe and keeps me practising properly.

How your information is used. Your details are held securely and used only to provide your treatment safely. They are never shared with any third party without your express permission. You may ask to see, correct or delete your record at any time by contacting me. Records are kept for as long as required by my professional insurer and UK law.

Please confirm you understand and agree *

Keeping in touch (optional)

I’d love to share occasional offers and wellbeing notes, only if you’d like. You can opt out any time.

Email SMS Phone Post

Signature (type your full name) *

Date *

Completing this for someone else? If the client is under 16, or an adult who needs support to consent, please add your details below.

Your name

Relationship to client

Your signature

A little about you

What brings you to reflexology?

Medical history

How are things right now?

Medication & everyday life

Your consent

Thank you.