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West Seattle Reflexology

Nicole Nicolaisen, Certified Reflexologist

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

Medical Information

Are you taking medications or supplements?

Do you smoke?

Any recent major illnesses, accidents, or surgeries?

Any allergies or sinus condition?

Do you currently have issues with your feet?

Is this your first reflexology session?

Are you undergoing other therapies?

Are you under stress?

Do you sleep well?

Other Information