Reflexology Intake Assessment (Initial Visit)

Date of Service: [Date]

Client Name: [Full legal name]

Date of Birth: [MM/DD/YYYY]

Preferred Name/Pronouns: [Preferred name and pronouns] (Only include if provided)

Practitioner Name & Credentials: [Name, credentials]

Location: [Clinic/site]

Chief Concern & Goals

Client-stated reason: "[Quoted client statement]" (Use exact phrasing in quotes when available)

Clinical summary: [Brief paraphrase of primary concerns and context]

• Short-term goal 1: [Goal]
• Short-term goal 2: [Goal] (Only include if provided)
• Short-term goal 3: [Goal] (Only include if provided)

Long-term goals: [Longer-range outcomes] (Only include if stated)

Client definition of success: [What improvement looks like to client, in measurable terms when possible]

Prior reflexology/bodywork experience: [Modalities tried, outcomes, frequency] (Only include if mentioned)

Pressure/sensory preferences: [Light / Moderate / Firm; texture, temperature, or scent preferences or aversions] (Only include if mentioned)

Informed Consent

Consent Obtained: [Yes / No]

Consent Method: [Written signature / Electronic signature / Verbal (documented)]

Consent Provided By: [Client / Parent-Guardian / Authorized Representative] (Specify relationship if not client)

Date/Time Obtained: [MM/DD/YYYY HH:MM]

Elements discussed and confirmed:

• Nature and purpose of reflexology and what to expect
• Scope limitations and non-medical disclaimer (reflexology does not diagnose, prescribe, or cure)
• Potential benefits framed as wellness outcomes
• Possible responses: temporary tenderness, lightheadedness, emotional release, fatigue
• Contraindications and possibility of modifying or deferring care
• Alternatives: no treatment, self-care, or consulting a licensed clinician
• Client right to ask questions and to stop or modify at any time
• Privacy and confidentiality practices

Client questions addressed: [Questions and responses provided] (Only include if questions were asked)

(If consent not obtained, document reason and state: "No treatment provided.")

Health History

(Capture client-reported information relevant to safe touch-based care. Do not infer diagnoses.)

• Current medical conditions: [List conditions] (Note especially: diabetes, neuropathy, vascular disease, clotting disorders, cancer treatment, autoimmune conditions, skin conditions, recent infections/fever, pregnancy/postpartum status, cardiac history, seizure disorders)
• Past surgeries/procedures: [List with approximate dates]
• Foot/ankle/leg history: [Significant injuries, chronic issues, prosthetics/orthoses]
• Medications and supplements: [List names] (Flag: anticoagulants, antiplatelets, steroids, immunosuppressants)
• Allergies/sensitivities: [Medications, latex, adhesives, lotions, oils, scents] (If none reported, state: "No known allergies reported.")
• Primary care clinician: [Name, practice] (Only include if provided)

Contraindications Screening

(Record response for each item. Do not document "no contraindications" unless screening was completed.)

• Fever or acute infectious illness today: [Yes / No / Unsure] [Details if yes]
• Open wounds, unhealed lesions, or skin infection on feet/hands: [Yes / No / Unsure] [Location if yes]
• Foot fractures, sprains, acute gout flare, or severe localized inflammation: [Yes / No / Unsure] [Location if yes]
• Known/suspected thrombosis or embolism history or current symptoms: [Yes / No / Unsure] [Details if yes]
• Significant circulatory compromise or vascular disease of legs/feet: [Yes / No / Unsure] [Details if yes]
• Pregnancy status: [Not pregnant / 1st trimester / 2nd trimester / 3rd trimester / Postpartum]
• Recent surgery (especially lower extremity): [Yes / No] [Procedure and date if yes]
• Severe unexplained pain, swelling, rash, or neurologic deficit: [Yes / No / Unsure] [Details if yes]

Disposition: [Safe to proceed / Safe to proceed with modifications / Defer care / Defer pending medical clearance]

Required modifications: [Avoid affected areas / Reduce pressure / Shorten duration / Use gloves / Other] (Include rationale; only include if modifications required)

Baseline Symptom Ratings

(Document up to three primary concerns. If client declines numeric ratings, use qualitative descriptors.)

1. Symptom/Concern: [Name]

   Intensity (0–10): [Rating]

   Frequency/Duration: [How often; since when; typical duration]

   Functional impact: [None / Mild / Moderate / Severe]

   Triggers/Relieving factors: [List if known]

2. Symptom/Concern: [Name] (Only include if applicable)

   Intensity (0–10): [Rating]

   Frequency/Duration: [Details]

   Functional impact: [None / Mild / Moderate / Severe]

   Triggers/Relieving factors: [List if known]

3. Symptom/Concern: [Name] (Only include if applicable)

   Intensity (0–10): [Rating]

   Frequency/Duration: [Details]

   Functional impact: [None / Mild / Moderate / Severe]

   Triggers/Relieving factors: [List if known]

Objective Observations

(Document only what is observed. Describe findings without assigning medical diagnoses.)

• Skin integrity: [Intact / Dry / Cracked / Callosities / Other] [Location]
• Color changes: [None / Pallor / Erythema / Cyanosis / Mottling] [Location]
• Swelling/edema: [None / Mild / Moderate / Severe] [Location]
• Bruising: [None / Present] [Location and size if present]
• Temperature differences: [Equal / Cool / Warm] [Location]
• Notable lesions: [Description with location] (Only include if present)
• Hygiene/infection control notes: [Observations, additional precautions needed] (Only include if relevant)
• Medical evaluation advised: [Yes / No] [Reason provided to client] (Only include if yes)

Assessment

[1–3 sentence summary linking client goals, key history findings, and safety considerations. State appropriateness for reflexology today, required precautions, and priority focus areas.]

Session Plan

• Modality: [Foot / Hand / Ear / Combination]
• Positioning & bolsters: [Supine / Reclined / Seated / Other] [Bolster locations]
• Planned duration: [Minutes]
• Pressure level: [Light / Moderate / Firm] (Within client comfort; adjust per feedback)
• Products: [Oil / Lotion / Balm / None] (Note allergy considerations)
• Priority focus areas: [Reflex areas or zones with rationale]
• Areas to avoid/modify: [Areas and specific modifications with safety rationale] (Only include if applicable)
• Safety parameters: [Client cue to pause/stop; signs to adjust; comfort monitoring]
• Home care guidance: [Hydration, gentle self-care, relaxation strategies] (Wellness-focused; not medical advice)
• Follow-up recommendations: [Suggested frequency] | Reassessment plan: [Outcomes or ratings to recheck]

Session Delivered

(Include this section only if reflexology was performed during this visit. If no session occurred, state: "No reflexology provided today (intake only).")

• Start–End Time / Duration: [HH:MM–HH:MM / Total minutes]
• Interventions performed: [What was done; sequence/areas; any deviations from plan]
• Client tolerance and responses: [Comfort level, pressure tolerance, notable responses]
• Adverse events: [None / Description of event and actions taken]
• Aftercare reviewed: [Hydration, expected post-session sensations, when to seek medical care]

Signatures

Practitioner Signature: [Name, credentials, date, time]

Client Signature for Consent: [Signature or verbal consent attestation with date/time]

(For late entries, addenda, or corrections: append a labeled note with current date/time, author, and reason. Do not overwrite the original.)