Reflexology Registration Form Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Date of BirthGenderFemaleMaleOtherAddressPhoneProfessionStress LevelsLowMediumHighGP AddressMedical HistoryCurrent Physical IssuesMuscular/SkeletalDigestive ProblemsCirculatory ProblemsGynaecologicalNervous SystemImmune SystemPregnantYesNoNo of Weeks PregnantIssuesMedication TakenAbility to RelaxGoodPoorHobbiesSleepGoodPoorExerciseSmokerYesNoIf yes, how many per dayAlcoholYesNoUnits Per WeekFood AllergiesDietFruitVegProteinDairyDrinksTeaCoffeeWaterJuiceCansOtherFood SupplementsHerbal SupplementsSkin TypeFood DisordersOver eatUnder eatBingeingAllergiesReferred for Reflexology byWould you like to join our Email list to receive news and special offers?YesNoOther issues/important informationHave you had a holistic therapy in the last 72 hrs?Reason for ReflexologyConsent *YesNoThis info I have provided is correct and true to the best of my knowledgeSigned *Dated *Send Form
