CLIENT HEALTH INTAKE FORM Client Information: Your Full Name (*) Cell Phone(*) Please list areas of tension, stress and/or pain you wish to be addressed (*): Please list any areas you prefer NOT to be worked on (*): - Have you ever had reflexology before? (*): YesNo Health Information: - Please mark any of the following that you now have or have had (*): Neuropathy Joint Replacement Muscle/bone injuries Pregnancy N/A Blood clots Heart attack Neck/back/spinal disorder Sciatica Other Injuries/accidents/illnesses still affecting you: Please read the following information and sign below: 1. I understand that if I experience any unusual discomfort and/or pain during my session it is my responsibility to inform the reflexology technician so that they can adjust the pressure or technique being used. 2. I understand that although reflexology can be very therapeutic, relaxing and reduce muscular tension, it is not a substitute for medical examination, diagnosis and treatment. 3. Some dizziness, soreness, minor bruising, or mild pain may occur after or during a treatment. 4. I have stated all my known physical conditions, and I will keep the reflexology technician updated on any changes. 5. This is a therapeutic health aide and any sexual remarks or advances will terminate the session and I will be liable for payment of the scheduled treatment. 6. I affirm the information on this client form is true and complete and I have read and agree to its contents. Therefore, I agree to indemnify and hold harmless the technicians and Bangkok Reflexology from any and all damages and losses. SIGNATURE HERE* (Click on clear button to clear Signature) Your full name/ Date (MM.DD.YYYY) (*): All your personal information is kept confidential and will not be shared with anyone outside of Bangkok Reflexology.