Birthday*

Relationship status*

Please tick any that apply

How much alcohol do you drink?*

Please rate your current stress levels *

How is your water intake daily*

How would you rate your sleep quality?*

Have you had Reflexology before?*

Are you able to physically move from a chair to the couch?*

Please tick any of the statements below that apply to you. These are possible contraindications to reflexology so I may be in touch for more details before your appointment.

Date