Health Form | TBR Flex

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Health Form

Please take a moment to fill out the form.

First Name

Last Name

Enter D.O.B * required

Gender *

Male

Female

Other

Prefer not to say

Occupation

GP Surgery

Please list any allergies

Please list any previous surgery (including the year)

Please list any chronic/ongoing medical conditions

Please list any acute medical conditions in the past 12 months

Please list any current medication

Are you pregnant? *

Yes

No

If yes, how many weeks?

What is your reason for reflexology?

Any other comments?

Thanks for submitting!

Lucinda Troostwyk

07962361711 | lucinda@tbrflex.co.uk

© 2023 by Lucinda Troostwyk.

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