FYS Online Consultation Form

Feet Your Soul Consultation Form

**All information here disclosed is strictly confidential
Have you ever had:

ReflexologyReikiEar CandlingIndian Head MassageNever had any of these treatment
When was the last time you received a treatment?
How did you hear about us?

Dublin Wellness Centre websiteNRRI WebsiteFriendFlyersFacebookInstagramGoogle SearchOther
Personal Information
Name

First NameLast Name
Age
Date of Birth

MonthDayYear
Date
Occupation
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
E-mail
Reason for your visit
Emergency Contact
Name

First NameLast Name
Phone Number

Area CodePhone Number
Relation
GP Name and Address
Medical history
List past surgeries or major medical problems/illness*
List of Medication*
Do you have any allergies? If yes, please list all your allergies
Please select if you suffer from any of these conditions

ArthritisInjuriesFracturesAches or muscle/joint painSkin conditionsEczemaPsoriarisAthlete's FootHigh blood PressureLow blood pressureThrombosisVaricose veinsFluid RetentionMedical OedemaSwelling in lymph glandsFrequent infectionKidneysHeartDiabetesRespiratory issuesConstipationBloatingDiarrhoeaIBSOther digestive issuesAsthmaSinusesHigh feverCancerEpilepsyMultiple SclerosisPinched NerveInflammationBladder/kidney infectionCompromised Immune systemInfectionTMJMigrainesStressAnxietyDepressionInsomniaTensionMood wings
Related to the ear- please select if any of the following conditions apply to you

Cochlear ImplantEar infectionEar drum perforationGrommets
**Women's Health- Please select if any of the following symptoms conditions apply

PCOSPMSIrregular periodsHeavy periodsPainful periodsMenopauseHRT (Hormone Replacement Therapy)Contraceptive PillCoilHot flushesMood swingsEndometriosisFertility issuesPregnancyAmenorreaFibroidsOther
**If trying to conceive, for how long have you been trying?
**Have you and/or your partner done any fertility tests? Please add any important information here including any undergoing treatments including, medication, hormonal imbalances or medical diagnose if applicable.
***ONLY FOR PREGNANCY- Please select if any of these apply

History of spontaneus miscarriageUnder 13 weeks pregnantSkin rashesInsomniaBackachesPelvic PainOedemaCirculatory problems, e.g. blood clotsPain at the front / back of your pelvisGestational DiabetesAbnormal vaginal bleedingPre-eclampsiaEpilepdyAbnormal placental function or positionBreech positionOther
***At what week of your pregnancy stage are you at this moment?
***Whas this pregnancy conceived naturally?

YesNoOther
***What test/ scans have you done?
***Due delivery date:

MonthDayYear
Date
***Have you ever had any complications during your pregnancy?
***Any history of miscarriadges?
***Is this your first pregnancy?
***If no to the two above answers, how many other children do you have and ages?
***Are you undergoing any physical activities during your pregancy? If yes, please list them
Lifestyle
Do you smoke?

YesNoOcassionallyUsed to smokeOther
From 1 to 10 (10 being the highest), rate your levels of stress at work and home
From 1 to 10 (10 being the healthiest), how healthy do you consider your diet to be?
My sleep is...

PoorI have difficulties falling asleepI wake up in the middle of the nightI feel more active at night and I struggle to wake up in the morningI sleep less than 7hMy sleep is greatOther
Do you drink caffeine? If yes, please specify the source and how many cups per day
Authorization/Consent

***Please read and tick below***
- I hereby declare that I have answered the consultation fully and I have not withheld any information that may affect the outcome of the treatment. I know of no reason why I cannot undertake the treatment. It is my responsibility to notify the therapist of any medical changes that may affect any treatment either now or in the future.
- I hereby authorize Feet your Soul to gather all the necessary details needed for my appointment to ensure the safety of both the patient and the therapist.
- The personal information you provided will be securely saved to meet GDPR regulations and will only be kept and used by Feet Your Soul healing therapies for insurance purposes as well as to help plan safe and effective treatments. The personal information enclosed during your treatments is strictly confidential and will not be shared with any third parties without your prior consent.
- I understand that the treatments I am receiving are complementary therapies and are not a substitute for medical care. I understand that practitioners do not diagnose conditions, nor do they prescribe or perform medical treatment, prescribe substances, nor interfere with the treatment of a licensed medical professional.
- If you experience any medical condition and have not seen your doctor yet, I recommend you to do so today.
Consentment- Please tick the boxes

I am happy to join the mail list in order to receive occasional emails/text regarding any important updates including: changes in business (ie. increase of current rates, change of venue, etc.), information regarding new treatments and appointments, special offers, classes and workshops. I understand that I can unsubscribe easily any time I wish.
Name & signature of patient/legally responsible person*

Clear
Date Signed

MonthDayYear
Date
Should be Empty:

Feet Your Soul Consultation Form

Personal Information

Emergency Contact

Medical history

Lifestyle

Authorization/Consent