Rate on a scale from 1 – 5 (1 being poor to 5 being excellent):

Rate on a scale from 1 – 5 (1 being poor to 5 being excellent):

Rate on a scale from 1 – 5 (1 being poor to 5 being excellent):

Rate on a scale from 1 – 5 (1 being poor to 5 being excellent):

Rate on a scale from 1 – 5 (1 being poor to 5 being excellent):

I have completed this form to the best of my ability and knowledge and agree to inform my reflexologist if any of the above information changes at any time.

By signing below, I hereby declare that I have accurately and honestly updated my therapist about any changes or
developments of my health and current wellbeing prior to each therapy session.