New Client Information – The Relaxation Room

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Home
Treatments
Gift Certificates
About
- Gallery & Feedback
Contact
The Resting Space
- About The Resting Space
- The Resting Space Accommodation
SHOP

New Client Information

Your client file is kept in an encrypted folder (Cryptomator) within my Advanced Data Protection iCloud account.

Your Name (first and last) *

Are you pregnant? *

Yes, first trimester
Yes, second or third trimester
No

Thanks for letting me know.

Neither reflexology nor massage is recommended for a person in the first trimester of their pregnancy. I would love to see you when you are in your second or third trimester. All the best with the baby 🙂 - Dee.

Are you presently receiving treatment for Cancer? *

No
Yes
Yes, I am receiving care aimed at comfort and quality of life.

I have post grad training in working with people with Cancer. However, I do recommend that you talk with your team about receiving reflexology.

Are you presently receiving chemotherapy (including oral chemotheraphy)?

No
Yes

This is so I know to wear personal protective gear 🙂

Do you have blood clots (or a history of blood clots)? *

No
Yes

Thanks for letting me know.

Both reflexology and massage encourage increased circulation.
Please check with your health provider that it's ok for you to have reflexology or relaxation massage before making an appointment - thanks, Dee.

Please indicate your age: *

Under 18 years
18 years to 30 years
31 years to 50 years
50 years to 70 years
over 70 years

Email *

body? you anything

I would like to receive emails updates from the Relaxation Room: *

Yes
No

Your inbox won't be flooded 🙂 Emails tend to be monthly, or when I have some news I'd like to share.

Your text/cellphone number. *

Emergency phone number *

I've never had to use this, but it's safe practice to have this information.

I will not have had any vaccinations in the 48 hours prior to my appointment. *

Agree

I am booking in for: *

Reflexology
Relaxation Massage (only available in Tokomaru)
Relaxation Massage / Reflexology Combo (only available in Tokomaru)

Are you looking for support concerning menopause or menstruation symtoms?

No
Yes

Where are you at?

I'm perimenopausal (still getting periods)
I'm menopausal (waiting for my 12 months of no periods to finish)
I'm post menopausal (but still experiencing symptoms)
I have Polycystic Ovary Syndrome (PCOS)
I have Endometriosis
I experience disruptive Premenstrual Tension (PMT)
Other

Check any that apply 🙂

Please briefly describe the symptoms that most concern you.

Please let me know if you have any of the following: *

Any inflammation due to injury e.g. sprained ankle
A skin condition that is carried through the blood e.g. boils
Varicose veins
None of the above

If you have, we can chat details when you come for your appointment.

Do you experience pain or discomfort in any part of your body?

Yes
No

Please give me a brief description of areas and levels of discomfort.

What are the most common reasons for you to visit a doctor or practice nurse? *

High or low blood pressure / angina / heart attack / stroke / blood clots
muscle - bone - ligament injury / arthritis / surgery / fibromyalgia
Skin conditions / allergies
Anxiety / depression / insomnia / parkinson's / neuropathy / numbness
Other
I very rarely go to the doctor.

We can chat details when you come for your appointment.

If 'Other', please give a brief summary:

Are you currently taking any medications or nutritional supplements? *

Yes
No

What is the reason for taking this medication/supplement?

Just a brief plain English summary is fine:) E.g. blood pressure meds, meds for water retention, meds for angina, type 1 or 2 diabetes etc.

What surgeries or procedures have you had?

Just a quick overview in plain English is fine 🙂 e.g surgery for broken wrist, hysterectomy, tonsils out as an adult etc.

How do you know when you (or your body) is under stress?

The information I have provided is true and accurate to the best of my knowledge and I have not withheld any information that might affect the course of my treatment. I will inform The Relaxation Room (Dee Hyde) if anything changes in the future. *

Agree

I understand that the treatments provided are to promote stress reduction throughout the entire body, to bring about relaxation, to promote balance and normalisation of the body, and to stimulate circulation and the delivery of oxygen and nutrients to the cells. They are not offered as a substitute for medical care. *

Agree

I understand that Dee Hyde does not diagnose illness or disease, nor perform any spinal manipulations, and does not prescribe any medications or treatments. I acknowledge that treatments provided by The Relaxation Room are not substitutes for a medical examination or diagnosis, and that I should see my health care provider for those services. Services in the Relaxation Room are not claimed to be effective for every ailment, client or specific condition. *

Agree

I understand that I am receiving treatments at my own risk. In the event that I become injured either directly or indirectly as a result, in part or in whole, of the aforesaid treatments, I hereby hold harmless and indemnify Dee Hyde from all claims and liability whatsoever. *

Agree

If I am unable to attend my scheduled appointment, I will respect and abide by the set cancellation policies. Sexual advances, requests for sexual favors, and any other verbal or physical conduct of a sexual nature will be considered sexual harassment and will not be tolerated. *

Agree

When you click on the submit button you should get a message popping up that says thanks for submitting the form.

If this doesn't happen, please let me know by texting me on 021 517 036. Thanks, Dee.

The Relaxation Room

Reflexology in Palmerston North, Levin and Feilding.