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Client Intake Form

Please fill out this form before your scheduled service so that Karen has your health and wellness information before she works on you. Your information will never be shared elsewhere. This may seem like a long form but your honesty regarding your health and wellbeing will help Karen to pinpoint certain areas, as well as avoid certain areas that may have contraindications. This is a judgment free zone.

First name*

Last name*

Address

Email*

Phone*

Emergency Contact Name and Phone*

Referred By

What brings you in today?*

What are your top 3 areas of concern?*

What are you hoping to achieve from today's session?*

Are there any specific challenges or concerns we should be aware of?*

CURRENT SYMPTOMS: Are you experiencing any pain or discomfort, where and how severe? Please rate on a scale of 1-10, with 1 being the lowest and 10 being the highest.*

How long have you been experiencing these symptoms?*

What makes them better or worse?*

Have you ever experienced Reiki-Infused Reflexology or energy work or do you have sensitivity to touch?*

MEDICAL HISTORY: Do you have any diagnosed medical conditions?*

How long have you been experiencing these conditions?*

Have you had any recent surgeries or injuries?*

Are you currently under a physicians care?*

Have you ever had blood clots, heart disease, or cancer?*

CURRENT MEDICATIONS & DOSAGES: What prescription medication do you take?*

What vitamins, herbs, or supplements do you use regularly?*

Do you have any allergies, sensitivity to oils/aromatherapy, fragrances, or creams?*

CIRCULATION & FOOT HEALTH: Choose all that apply*

Diabetes

Neuropathy

Poor Circulation

Varicose Veins

Swelling in Legs or Feet

None

CONTRAINDICATIONS: Choose all that apply*

DVT/Blood Clots

Fever Contagious Illness

Acute Infection

Recent Surgery

Uncontrolled High Blood Pressure

Severe Edema of Unknown Cause

Broken Bones

Active Gout Flare

Open Wounds: If you have any open wounds, fungal infections, or severe injuries then Karen will not be able to provide reflexology until area is treated, pathogen-free, & healed.

None

LIFESTYLE: How would you rate your stress (1-10)*

How many hours do you sleep, and is it restful or interrupted?*

Describe your energy level:*

Describe your exercise routine:*

Describe your water intake:*

Describe your typical daily nutrition:*

Describe your alcohol, nicotine, or recreational drug use:*

EMOTIONAL WELLNESS: Are you feeling overwhelm, stress, anxiety, or grief? *

If you answered yes to the above questions, how long have you been experiencing these symptoms?*

Do you feel emotionally supported?*

What helps you relax?*

WOMEN'S HEALTH: are you pregnant or trying to become pregnant?*

If you answered yes to the above question, how many weeks along are you?

Are you experiencing menopause or any hormonal changes?*

If you answered yes to the above question, how long have you been experiencing these symptoms?

WELLNESS GOALS: What does “feeling well” look like to you?*

What areas would you like to improve over the next 3 months?*

Are you interested in:

Nutrition

Stress Reduction

Herbal Remedies

Breathwork

Relationship Coaching

Lifestyle Coaching

Tarot Card Readings

Oracle Card Readings

Akashic Records Readings

None

I understand that Reiki/Reiki-infused Reflexology & energy work supports relaxation and well-being and is not intended to diagnose, treat, or cure disease.

I consent to today’s session & continued sessions.

On a scale of 1-10 (1 being the lowest, 10 being the highest) Please rate your: stress, sleep, energy, digestion, pain, mood, mental clarity, immune health, hydration, overall wellness.*

Signature*

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SERVICES | ABOUT | BLOG

508-857-7736 | RootedHealingArtsMA@gmail.com

Hours of Availability (with some variation) exclusively at

Muscle Matters, in the Memorial Building, 246 E Main Street,Norton, MA

Fridays from 11-3

Every other Saturday from 11-3

Sundays from 11-3

Accessibility Statement

© 2026 Rooted Healing Arts. All Rights Reserved.

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