Reflexology Session Note (Pregnancy/Postpartum)

Date of Service: [date]

Session Duration: [minutes]

Setting: [clinic / home / telehealth consult / other]

Encounter Type: [Initial / Follow-up]

Client Name: [full name]

DOB: [DOB]

Practitioner: [name, credentials, certification]

Pregnancy/Postpartum Status & Safety Screen

Status: [Pregnancy / Postpartum] [gestational age (weeks+days) / weeks postpartum]

• Pregnancy details: [trimester], [EDD if known], [singleton/multiple if known], [client-reported high-risk factors or complications], [clearance status] (Only include if pregnant; include only elements explicitly reported.)
• Postpartum details: [delivery type if disclosed], [client-reported recovery considerations], [breastfeeding/chestfeeding status] (Only include if postpartum.)

Safety Screen: [brief notation of presence/absence of warning symptoms] (Use concise phrasing, e.g., "Denies chest pain, SOB, severe headache, vision changes, heavy bleeding, unilateral leg swelling, fever, thoughts of self-harm." If any positive: document the symptom, action taken, and client response. If client declines: note "not assessed—client declined" and your response.)

Subjective

[Brief HPI-style summary including primary reason for visit, onset/duration, current severity on 0-10 or similar scale, and client's goals for the session] (2-4 sentences; use client's words when helpful.)

Symptom Goals: [prioritized list of what client hopes to address]

Relevant History: [allergies to topicals, conditions affecting feet/hands, prior reflexology response] (Note "no changes from intake" if unchanged.)

Positioning & Intervention

Consent: [confirmation that client consented to session, understands wellness/supportive intent, and confirmed stop signal]

Position: [position used, supports, rationale, any time limits or repositioning]

Pressure: [gentle / moderate / firm] or [1-5 scale]

Areas Treated: [foot / hand / ear], [sides], [approximate duration per region]

Modifications: [areas avoided and why, pregnancy/postpartum-specific adjustments, rest breaks, hydration offered]

Topical: [product used / none]

Adverse Events: [None / description including onset, response, and outcome]

Response & Assessment

Immediate Response: [brief narrative of client-reported response and observed tolerance/comfort]

Pre/Post Rating: [pre-session rating] → [post-session rating] (client-reported)

New Symptoms: [none / description and actions taken]

Assessment Summary:

• [Session appropriateness]
• [Modifications that worked well or need adjustment]
• [Progress compared to prior sessions if follow-up]

(Avoid diagnostic language; frame all observations as client-reported or observed.)

Plan

Follow-up: [timing and focus for next session / reason if none planned]

Self-Care Education: [topics discussed and client understanding]

Coordination/Referral: [recommendation to discuss symptoms with OB/midwife, request for clearance, or urgent referral guidance] (Omit if none.)

Practitioner Signature: [signature with credentials and date/time]

(If entry is delayed, label as delayed entry with date/time of entry. For addenda or corrections, label clearly with author, date/time, and what changed. Do not claim prevention or treatment of obstetric conditions.)