Reflexology
Consultation Form Unit 381 - Provide Reflexology for Complementary Therapies
Centre Name: Kingston college Centre Number: Student Name: Donna Ryan Student Number: D116317 Date: 13 30 april Client Name: sally Address: charlton villiage Profession: keeper bee Tel. No: Day Eve
On file
PERSONAL DETAILS Age group: Under 20 20–30 30–40 40–50 50–60 60+ Lifestyle: Active Sedentary more Last visit to the doctor: than 6 months shepperton GP Address: 1 No. of children (if applicable): jan 13 Date of last period (if applicable): CONTRAINDICATIONS REQUIRING MEDICAL PERMISSION – in circumstances where medical permission cannot be obtained clients must give their informed consent in writing prior to treatment (select where/if appropriate): Pregnancy Cardiovascular conditions (thrombosis, phlebitis, hypertension, hypotension, heart conditions) Haemophilia Any condition already being treated by a GP or another complementary practitioner Medical oedema Osteoporosis Arthritis Nervous/Psychotic conditions Epilepsy Recent operations Diabetes Asthma Any dysfunction of the nervous system (e.g. Multiple sclerosis, Parkinson’s disease, Motor neurone disease) Bell’s Palsy Trapped/Pinched nerve (e.g. sciatica) Inflamed nerve Cancer Spastic conditions Kidney infections Whiplash Slipped disc When taking prescribed medication Acute rheumatism Undiagnosed pain
CONTRAINDICTIONS THAT RESTRICT TREATMENT (select where/if appropriate): Fever Contagious or infectious diseases Under the influence of recreational drugs or alcohol Diarrhoea and vomiting Pregnancy (first trimester) Skin diseases Localised swelling Inflammation sting Varicose veins Cuts Bruises Abrasions Scar tissue (2 years for major operation and 6 months for a small scar) Sunburn Hormonal implants Haematoma Recent fractures (minimum 3 months) Conditions/disorders of feet/hands Menstruation Disorders/conditions of hands/feet/nails
WRITTEN
Centre Name: Kingston college Centre Number: Student Name: Donna Ryan Student Number: D116317 Date: 13 30 april Client Name: sally Address: charlton villiage Profession: keeper bee Tel. No: Day Eve
On file
PERSONAL DETAILS Age group: Under 20 20–30 30–40 40–50 50–60 60+ Lifestyle: Active Sedentary more Last visit to the doctor: than 6 months shepperton GP Address: 1 No. of children (if applicable): jan 13 Date of last period (if applicable): CONTRAINDICATIONS REQUIRING MEDICAL PERMISSION – in circumstances where medical permission cannot be obtained clients must give their informed consent in writing prior to treatment (select where/if appropriate): Pregnancy Cardiovascular conditions (thrombosis, phlebitis, hypertension, hypotension, heart conditions) Haemophilia Any condition already being treated by a GP or another complementary practitioner Medical oedema Osteoporosis Arthritis Nervous/Psychotic conditions Epilepsy Recent operations Diabetes Asthma Any dysfunction of the nervous system (e.g. Multiple sclerosis, Parkinson’s disease, Motor neurone disease) Bell’s Palsy Trapped/Pinched nerve (e.g. sciatica) Inflamed nerve Cancer Spastic conditions Kidney infections Whiplash Slipped disc When taking prescribed medication Acute rheumatism Undiagnosed pain
CONTRAINDICTIONS THAT RESTRICT TREATMENT (select where/if appropriate): Fever Contagious or infectious diseases Under the influence of recreational drugs or alcohol Diarrhoea and vomiting Pregnancy (first trimester) Skin diseases Localised swelling Inflammation sting Varicose veins Cuts Bruises Abrasions Scar tissue (2 years for major operation and 6 months for a small scar) Sunburn Hormonal implants Haematoma Recent fractures (minimum 3 months) Conditions/disorders of feet/hands Menstruation Disorders/conditions of hands/feet/nails
WRITTEN