Contraindications & Safety Screening (Reflexology)

Patient name: [Patient full name]

DOB: [Date of birth]

Encounter date/time: [Date and time of session]

Location: [Clinic/site or setting]

Practitioner name and credentials: [Practitioner full name, credentials]

Modality: [foot reflexology / hand reflexology / both]

Visit type: [initial / follow-up]

Source of history: [patient / caregiver / family / medical record / interpreter / other] (Include only if source is not the client)

Session Context

Reason for session: [Client goal in 1–2 phrases, e.g., relaxation, stress relief, comfort, sleep support]

Areas planned: [Feet/hands and laterality if relevant]

Planned adjuncts: [Lotion/oil, hot towel, positioning, or none] (Include only if applicable)

Interval Health Status

(For follow-up visits, begin with attestation. Preserve exact client-reported language in quotes where applicable.)

[No changes reported since last reflexology visit / Changes reported]

• [New diagnoses or symptoms] (Include only if changes reported; use "unknown" or "declined" if client unsure or declines)
• [Recent procedures, surgery, or injury with dates if known]
• [New or changed medications affecting bleeding or sensation, e.g., anticoagulants, antiplatelets, steroids, chemotherapy]
• [Change in pregnancy status with trimester if known]
• [New skin or foot concerns]

(For initial visits:)

[Initial intake form reviewed today / New client—focused screening completed] [Brief relevant history if needed]

Safety Screening

(For each domain, indicate whether concerns are present. Use "none identified" or "denied" when negative. Document "unknown" or "declined" explicitly when information unavailable. Preserve quoted client language where provided.)

• Circulation and clot risk:
  • Concerns: [yes / no / unknown / declined]
  • Details: [DVT/PE history or treatment; unilateral leg swelling/warmth/redness/calf pain; recent immobility or surgery; vascular disease of feet; clinician restrictions; whether medically evaluated; clearance status] (Include only if concerns present or uncertain)
  • Planned action: [avoid area / defer session / proceed with caution / clearance on file / verbal clearance reported with source and date]
• Bleeding and bruising risk:
  • Concerns: [yes / no / unknown / declined]
  • Details: [Anticoagulant/antiplatelet use and recent changes; bleeding disorder; easy bruising; visible bruising today with location; medication name if known] (Include only if concerns present)
  • Pressure plan: [light / moderate / avoid specific areas]
• Pregnancy status:
  • Status: [pregnant with trimester / not pregnant / possibly pregnant / unknown / not applicable]
  • High-risk features or restrictions: [Details if any] (If uncertain, document uncertainty and apply conservative approach)
• Skin and foot integrity:
  • Concerns: [yes / no / unknown / declined]
  • Findings: [Open wounds, ulcers, fissures, blisters, active rash, suspected infection, fungal changes, warts, psoriasis/eczema flare, nail concerns with location] (Use "client reports" or "appearance consistent with" rather than definitive diagnoses; include only if concerns present)
  • Infection control/area management: [avoid area / barrier used / gloves / no topicals / cleaning protocol]
• Neuropathy and sensation:
  • Concerns: [yes / no / unknown / declined]
  • Details: [Diabetic or other neuropathy; prior foot ulcer or amputation; numbness or reduced sensation; ability to perceive pressure; areas affected] (Include only if concerns present)
  • Pressure limits: [light only / light–moderate / avoid areas with specification]
• Recent injury or acute inflammation:
  • Concerns: [yes / no / unknown / declined]
  • Details: [Fracture, sprain, acute bruising, surgery affecting treatment area, severe or unexplained edema with date] (Include only if concerns present)
  • Modification plan: [avoid area / lighter pressure / defer treatment / medical evaluation recommended]
• Cancer treatment or immunosuppression:
  • Concerns: [yes / no / unknown / declined]
  • Details: [Active chemotherapy/radiation; lymphedema risk; neutropenia or infection precautions; low platelet count; oncology team guidance] (Include only if concerns present)
  • Pressure/hygiene modifications: [light pressure / avoid affected limb or quadrant / gloves / enhanced hygiene]
• Acute illness:
  • Concerns: [yes / no / unknown / declined]
  • Details: [Fever, vomiting, diarrhea, respiratory symptoms, contagious illness exposure, cellulitis with onset/timing] (Include only if concerns present)
  • Action: [defer session / recommend medical evaluation / reschedule]

Pre-Session Observation

• Visual inspection performed: [yes / no] [Reason if not performed] (If not performed, treat skin integrity as unknown)
• Skin integrity: [intact / findings by location]
• Swelling: [none / mild / moderate / severe] [unilateral / bilateral] [location if present]
• Visible bruising: [none / present with location]
• Client-reported tenderness affecting plan: [none / location and brief description]

Disposition

Outcome: [Proceed as planned / Proceed with modifications / Defer session / Stop and refer]

Rationale: [Brief explanation linking to screening findings]

Medical clearance status: [written clearance on file / verbal clearance reported with source and date / none obtained / not required]

Modifications Implemented

(Include only when disposition is "Proceed with modifications")

• Pressure modification: [light / moderate] [Areas affected]
• Area avoidance: [Specific regions to avoid]
• Positioning modification: [seated / side-lying / supine with elevation / other]
• Duration modification: [shortened session / segment timing adjusted]
• Skin protection and hygiene: [gloves / barriers / no topicals / linen change / enhanced hand hygiene]
• Monitoring plan: [Check-in frequency and stop rules]
• Coordination: [Advised to consult provider / obtain clearance before next visit / share session summary with care team]

Client Communication

(Include when modifications made, session deferred, or referral indicated; omit when proceeding as planned with no notable findings)

• Client informed of findings and risks: [yes / no] [Summary of discussion]
• Client consent to proceed with modifications: [obtained / declined / not applicable]
• If deferred: [Reason communicated and recommended next steps]
• Aftercare instructions: [Instructions if relevant to session findings]

Signature

[Practitioner signature, credentials, date and time]

(If addendum or late entry, label as such with current date/time referencing original encounter)