About this template
The Reflexology Intake Form template is an essential tool for reflexologists, massage therapists, and wellness clinics aiming to streamline their client onboarding process. Before beginning any therapy session, it is critical to understand a client's health background, existing medical conditions, allergies, and treatment preferences to ensure a safe and effective session.
This comprehensive template collects vital personal details, emergency contacts, current medications, pregnancy status, past surgeries, and specific areas to avoid during treatment. By gathering this health information in advance, practitioners can tailor their reflexology sessions to each individual's unique needs while identifying any potential contraindications.
Using Doc2Form, you can instantly turn this structured layout into a ready-to-use Google Form, allowing clients to submit their details smoothly from any smartphone, tablet, or computer before arriving at your studio.
Key features
- Collect detailed health history and medical conditions prior to treatment.
- Ensure client safety by screening for allergies, medications, and past surgeries.
- Gather emergency contact information and client personal details in one place.
- Fully optimized for mobile devices so clients can complete it on the go.
- Easily customize questions to match your specific clinic or spa requirements.
Use cases
- New client onboarding at holistic health and reflexology clinics.
- Pre-treatment health screenings for mobile massage therapists.
- Spa wellness consultations requiring liability and health disclosures.
What this form collects
- Full Name (Short answer)Enter your first and last name.
- Email Address (Short answer)We will use this to send appointment confirmations and session notes.
- Phone Number (Short answer)Best number to reach you regarding your appointment.
- Date of Birth (Date)Please provide your birth date.
- Gender (Dropdown)Select your gender identity.
- Home Address (Paragraph)Enter your street address, city, state, and zip code.
- Emergency Contact Name (Short answer)Full name of someone we can reach in case of an emergency.
- Emergency Contact Phone Number (Short answer)Phone number for your emergency contact.
- Primary Reason for Visit (Paragraph)What specific symptoms, stress factors, or goals bring you in today?
- Is this your first time receiving reflexology? (Multiple choice)Let us know if you are new to this type of therapy.
- Do you have any known allergies? (Multiple choice)Include sensitivities to oils, lotions, latex, or scents.
- Allergy Details (Paragraph)If you answered yes, please list your allergy triggers and severity.
- Are you currently taking any medications? (Multiple choice)Include prescription drugs, over-the-counter medicines, or herbal supplements.
- Current Medications List (Paragraph)Please list the names of medications you are currently taking.
- Are you pregnant? (Multiple choice)Certain reflexology points are contraindicated during pregnancy.
- Medical History & Conditions (Checkboxes)Select any conditions you currently experience or have experienced in the past.
- Areas to Avoid (Paragraph)Are there any specific areas on your feet or ankles you do not want touched due to pain or sensitivity?
- Consent and Agreement (Short answer)By typing your full name below, you confirm that the information provided is accurate to the best of your knowledge and that you consent to receiving reflexology treatment.
- Date Signed (Date)Enter today's date.
FAQ
How do clients fill out this reflexology intake form?
Once you convert this template using Doc2Form, you can simply share the Google Form link via email, text message, or embed it on your website for clients to complete before their appointment.
Can I add or remove questions from this form?
Yes! Because the template lives in your Google Drive as a standard Google Form, you have full control to add, edit, or delete any fields to suit your practice.
Is this form mobile-friendly?
Absolutely. Google Forms automatically adjusts to display cleanly on smartphones, tablets, and desktop computers.
What kind of health information does this form capture?
It covers essential wellness metrics including current medications, allergies, pregnancy status, past surgeries, specific health conditions, and any bodily areas the client prefers to avoid.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.