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Health Intake Form

Date of Birth
Month
Day
Year

Symptoms, Frequency and Length you've suffered with condition (for each)

Type and Year of Surgery

if you have a list available, please upload here for your convenience

Pain, Tenderness, Sore Spots, Wounds, Amputations, any other Abnormality.

Do you Currently have Athlete's Foot, Fungal Infection or a Wart on your feet?
YES
NO

If Yes, please see your Primary Care Provider for diagnosis and treatment.

Reflexology can be completed as long as the skin is intact and the Reflexologist will wear gloves during your treatment.

Sensitivity to Essential Oils, Topically?
YES
NO
Sensitivity to Lotion, Topically?
YES
NO
Do you Agree to using Essential Oils and Lotions topically during your treatment?
YES
NO
Any Prosthetics or Issues from the Hip down?
YES
NO

Using a 0-10 Scale (0 is least, 10 is worst)

What has brought you to try Reflexology?

Including diet, exercise, hobbies, recreational activities

What are you hoping for our of Reflexology?

Date
Month
Day
Year

If someone referred you, please include their name

ACCESSIBILITY STATEMENT 

Text & Call 

519-257-9292

data rates may apply

Email 

jessicaserre@gmail.com

​Medical Disclaimer: Jessica Serre, Serenite Wellness and Suture Self Holistic do not replace medical care or treatments. If you have a medical emergency, please call 911 or go to the nearest emergency room. If you are under the care of a Primary Care Provider or Specialist, please consult them prior to initiating Complimentary Alternative Medicine Care. 

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