JENNIFER SKINNER R·C·R·T REGISTERED CANADIAN
REFLEXOLOGY THERAPIST

Let’s get you set up

A few details so Jennifer can tailor your session and keep it safe for you. It takes about three minutes, and everything you share is encrypted and kept private.

Your details
Your visit
About your health
Are you presently experiencing any of the following?
Consumption / activity level

Indicate your usual level for each.

Salt
Sugar
Caffeine
Tobacco
Alcohol
Cannabis
Water
Exercise
Health conditions

Check the appropriate answer for each. Leave blank if it does not apply.

Endocrine — Diabetes
Endocrine — Hypoglycemia
Endocrine — Menopausal problems
Endocrine — Hypothyroidism
Endocrine — Hyperthyroidism
Urinary — Kidney disease
Urinary — Kidney stones
Urinary — Urinary problems
Cardiovascular — Heart disease
Cardiovascular — Phlebitis
Cardiovascular — Varicose veins
Cardiovascular — Circulation problems
Cardiovascular — Anemia
Immune / Lymphatic — Arthritis
Immune / Lymphatic — Chronic fatigue
Immune / Lymphatic — HIV / AIDS
Musculoskeletal — Osteoporosis
Musculoskeletal — Fibromyalgia
Musculoskeletal — Bursitis
Musculoskeletal — Gout
Musculoskeletal — Back pain
Musculoskeletal — Scoliosis
Musculoskeletal — Foot / arm / hand problems
Respiratory — Asthma
Respiratory — COPD
Respiratory — Emphysema
Respiratory — Tuberculosis
Nervous — Vision
Nervous — Hearing loss / problems
Nervous — Nerve pain / damage
Nervous — Mental health issues
Nervous — MS
Reproductive — PMS
Reproductive — Endometriosis
Reproductive — Prostate problems
Digestive — Constipation
Digestive — Diarrhea
Digestive — Crohn’s disease
Digestive — Colitis
Digestive — Diverticulitis
Digestive — Ulcer
Skin — Psoriasis
Skin — Eczema
Skin — Warts
Other — Hepatitis
Other — Herpes
Other — Cancer
Anything to specify about the above
Consent

I, the undersigned, consent to Reflexology treatment and understand that the sessions are for stress reduction and relaxation. Reflexology does not substitute for medical examination, diagnosis, or treatment and I will consult a physician, or other qualified medical specialist for all my mental or physical ailments of which I am aware. I may stop the session at any time, either during the assessment or the treatment. Reflexology therapists do not diagnose, prescribe, treat for specific conditions or use tools of any kind. I confirm that I have informed the therapist of my known medical conditions and answered all questions honestly. Should I seek further Reflexology treatment from the therapist, I agree to update them as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part should I forget to do so.

Your information is encrypted before it is stored and is used only for your care.

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