Consultation Form

iUCT32 – Provide reflexology for complementary therapies

Centre name:

Centre number:

Learner name:

Learner number:

Date:

Client name:

Address:

Profession:

Telephone number: Day:

Evening:

Personal details:
Age group: Under 20 ☐ 20 – 30 ☐ 30 – 40 ☐ 40 – 50 ☐ 50 – 60 ☐ 60+ ☐

Lifestyle: Active ☐ Sedentary ☐

Last visit to the
doctor:

GP Address:

Number of children:
(If applicable)
Date of last period:
(If applicable)

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 Contra-indications requiring medical permission – in circumstances where medical permission cannot be
obtained clients must give their informed consent in writing prior to treatment (Select if/where
appropriate):
Pregnancy ☐ Epilepsy ☐ Cancer ☐
Cardiovascular conditions
(thrombosis, phlebitis, Conditions causing muscular
☐ Recent operations ☐ ☐
hypertension, hypotension and spasticity (e.g. cerebral palsy)
heart conditions)
Haemophilia ☐ Diabetes ☐ Kidney infections ☐
Any condition already being
treated by a GP or another ☐ Asthma ☐ Whiplash ☐
complementary practitioner
Any dysfunction of the nervous
system (e.g. multiple sclerosis,
Medical oedema ☐ ☐ Slipped disc ☐
Parkinson’s disease, motor
neurone disease)
When taking prescribed
Osteoporosis ☐ Bell’s palsy ☐ ☐
medication
Trapped/pinched nerve (e.g.
Arthritis ☐ ☐ Acute rheumatism ☐
sciatica)
Nervous/psychotic conditions ☐ Inflamed nerve ☐ Undiagnosed pain ☐

Contra-indications that restrict treatment – (Select if/where appropriate):

Fever
Contagious or infectious
diseases
Under the influence of
recreational drugs or alcohol
Diarrhoea and/or vomiting
Skin diseases
Undiagnosed lumps and bumps ☐
Sunburn
☐ Inflammation
☐ Varicose veins
☐ Pregnancy (first trimester)
☐ Bruises
☐ Abrasions
Scar tissue (2 years for major
operation and 6 months for
small scar)
☐ Localised swelling
☐ Hormonal implants ☐
☐ Haematoma ☐
Recent fractures (minimum 3
☐ ☐
months)
Conditions/disorders of
☐ ☐
feet/hands
☐ Menstruation ☐
Disorders/conditions of
☐ ☐
hands/feet/nails
☐ Cuts ☐

Written permission required by – Either of which should be attached to the treatment form (Select
if/where appropriate):
GP/specialist ☐ Informed consent ☐

Personal information – (Select if/where appropriate):

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 Muscular/skeletal
Back ☐ Aches/pain ☐ Stiff joints ☐ Headaches ☐
problems:
Digestive
Constipation ☐ Bloating ☐ Liver/gall bladder ☐ Stomach ☐
problems:
Heart ☐ Blood Pressure ☐ Fluid retention ☐ Tired legs ☐
Circulation: Cold hands and
Varicose veins ☐ Cellulite ☐ Kidney problems ☐ ☐
feet
Irregular
☐ P.M.T ☐ Menopause ☐ H.R.T ☐
Gynaecological: periods
Pill ☐ Coil ☐ Other:
Nervous system: Migraine ☐ Tension ☐ Stress ☐ Depression ☐
Prone to infections ☐ Sore throats ☐ Colds ☐
Immune system:
Chest ☐ Sinuses ☐
Regular antibiotic
If yes, which
/ medication Yes ☐ No ☐
ones?
taken?

Herbal remedies If yes, which

Yes ☐ No ☐
taken? ones?

Ability to relax: Good ☐ Moderate ☐ Poor ☐

Average No.
Sleep patterns: Good ☐ Poor ☐
of hours
Do you see
natural daylight
Yes ☐ No ☐
in your
workplace?
Do you work at a If yes, how
Yes ☐ No ☐
computer? many hours?
Do you eat
Yes ☐ No ☐
regular meals?
Do you eat in a
Yes ☐ No ☐
hurry?
Do you take any
If yes, which
food/vitamin Yes ☐ No ☐
ones?
supplements?
How many Fresh Fresh Protein and
portions of each Fruit: Vegetables: source:
of these does your
diet contain per Dairy
Sweet things: Added salt: Added sugar:
day? produce:

How many of Tea: Coffee: Fruit juice: Water:

these drinks do
you consume per Soft drinks: Others:
day?

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 Do you suffer
from food Yes ☐ No ☐
allergies?
Do you suffer
from eating Yes ☐ No ☐
disorders?
Bingeing? Yes ☐ No ☐
Overeating? Yes ☐ No ☐
Undereating? Yes ☐ No ☐
How many per
Yes ☐ No ☐
Do you smoke? day?
Other:
Do you drink How many units
Yes ☐ No ☐
alcohol? per day?
None ☐ Occasional ☐ Irregular ☐ Regular ☐
Do you exercise?
Types:

What is your skin Dry ☐ Oily ☐ Combination ☐

type? Mature ☐ Young ☐
Do you Dermatitis ☐ Acne ☐ Eczema ☐ Psoriasis ☐
suffer/have
suffered from: Allergies ☐ Hay fever ☐ Asthma ☐ Skin cancer ☐
Stress level: 1- 10
(10 being the At work: At home:
highest)

Reading of the feet – (Select if/where appropriate):

Contra-
indications that
restrict:
Skin
texture/areas of
hard skin:
Colour:
Flexibility:
Temperature:
Swelling
/puffiness:
Odour:
Foot position:
Nail condition:
Skeletal
structure/arches
of the feet:

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 iUCT32 – Provide reflexology for complementary therapies – Treatment No:

Client name:

Treatment date:

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 Client profile– (To include lifestyle):

Treatment plan:

Client feedback:

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 Home care advice given including recommendations for self-treatment:

Self-reflection and evaluation of the treatment (this field to be completed for case studies only):

Any CPD requirements: – (this field to be completed for case studies only on conclusion of treatment
programme):

Therapist/learner signature: _______________________________________________________________________

Client signature: _________________________________________________________________________________

iUCT32_Consultation Form_v2 Page 7 of 11

Continuation sheet – Treatment No:
iUCT32 – Provide reflexology for complementary therapies
Client name:

Treatment date:

Reading of the feet:

Contra-
indications that
restrict:
Skin
texture/areas of
hard skin:
Colour:
Flexibility:
Temperature:
Swelling
/puffiness:
Odour:
Foot position:
Nail condition:
Skeletal
structure/arches
of the feet:

Treatment plan:

iUCT32_Consultation Form_v2 Page 8 of 11

 Client feedback:

Aftercare feedback:

Self-reflection and evaluation of the treatment– (this field to be completed for case studies only):

Any CPD requirements: – (this field to be completed for case studies only on conclusion of treatment
programme):

iUCT32_Consultation Form_v2 Page 9 of 11

 iUCT32 – Provide reflexology for complementary therapies – Treatment No:

Client name:

Treatment date:

Therapist/learner signature: _______________________________________________________________________

Client signature: _________________________________________________________________________________

iUCT32_Consultation Form_v2 Page 10 of 11

Document History

Version Issue Date Changes Role

v1 09/10/2019 First published Qualifications and Regulation Co-
ordinator
v2 10/01/2020 Re-published Qualifications and Regulation Co-
ordinator

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