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West Seattle Reflexology

Nicole Nicolaisen, Certified Reflexologist

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Intake Form

Your answers are strictly confidential. If you have any questions, you may reach me via my mobile phone at (206) 963-0986.

Contact Information

Name * Phone * Email Address * Email Address (confirm) * Preferred method of contact: Preferred Pronouns Mailing Address * Emergency Contact Name * Emergency Contact Phone *

Medical Information

Physician Name Physician Phone

Are you taking medications or supplements? Yes No

Do you smoke? Yes No

Any recent major illnesses, accidents, or surgeries? Yes No

Any allergies or sinus condition? Yes No

Generally speaking, how's your health?

Do you currently have issues with your feet? Yes No

Is this your first reflexology session? Yes No

Are you undergoing other therapies?
Acupuncture
Massage
Chiropractic
Physical Therapy
Other

What else do you do for your health? What is your occupation? Where do you feel the most tension in your body?

Are you under stress? Yes No

Do you sleep well? Yes No

Other Information

How did you find me?

Goals/Expectations

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© West Seattle Reflexology – Credits

I Am Open For Business!

Covid Updates

Masks are required for all appointments, regardless of vaccination status. I will also be wearing a mask.
I am also fully vaccinated and will continue to sanitize commonly touched surfaces.
The studio is equipped with a HEPA air filter.

I look forward to seeing you soon!

Nicole

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