0
Items :
0
Subtotal :
£
0.00
View Cart
Check Out
Home
Prep Coaching
Therapies
Consultation Form
Personal Training
Online Training
Buddy Up/Partner Training
Par Q form
Transformations Gallery
Experience
Competitive History
Qualifications
Home Workouts
Photo Shoots
Agreement Form
Contact
Information Sheet
Home
Prep Coaching
Therapies
Consultation Form
Personal Training
Online Training
Buddy Up/Partner Training
Par Q form
Transformations Gallery
Experience
Competitive History
Qualifications
Home Workouts
Photo Shoots
Agreement Form
Contact
Information Sheet
0
Items :
0
Subtotal :
£
0.00
View Cart
Check Out
Consultation Form
Sports Massage Consultation Form
Date:
*
Date Format: MM slash DD slash YYYY
Client Name:
*
DOB (Date of Birth)
*
DD
MM
YYYY
Age
*
Address
*
Height (m)
*
Weight (kg)
*
Mobile Tel No
*
Doctor Name
*
Surgery
*
Tel No
Occupation
Exercise Routine
Have you recently visited
*
Doctor
Consultant
Physio
Osteopath
Sports Therapist
Chiropractor
Acupuncture
Podiatrist
Massage
Other
Other
Are you currently taking medications?
*
Main reason of attending
*
Any current problem or known history of the following
*
Musculo-skeletal problems
Arthritis
Osteoporosis
Fractures
Joint replacement
Pins and plates
Heart
Circulatory
Arterial
Blood Pressure
Thrombosis
Embolism
Varicose veins
Diabetes
Epilepsy
Asthma
Allergy
Skin Conditions
*
Cuts
Bruises
Burns
Rashes
Scars
Warts
Moles
Pregnancies
Major Recent Illness
Major Recent Operations
*
Digestive
Urinary
Endocrine
Respiratory
Neurological Problems
Specific aches, pains, problems and injuries
*
Head
Neck
Third Choice
Thoracic
Lumbar
Sacral
Coccygeal
Abdominal
Shoulder girdle
Upper arm
Elbow
Lower arm
Wrist
Hand
Fingers
Pelvic
girdle
Hip
General Notes
*
Have you had a fever in the last 24 hours of the 100°F or above?
*
Yes
No
Do you now, or have you recently had, any respiratory or flu like symptoms sore throat or shortness of breath?
*
Yes
No
Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has corona-virus-type symptoms?
*
Yes
No
*
I understand that, because massage therapy work involves maintained touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including COVID-19. By singning this form, I acknowledge that I amaware of the risks involved from receiving treatment at this time, I voluntarily agree to assume those risks, and I relase and hold harmless the practitioner/business from any claims related thereto. I give my consent to receive treatment from this practitioner.
Client Signature
*
I understand that, because Personal Training can include some close proximity at times, there may be an elevated risk of disease transmission, including COVID-19. By signing this form, I acknowledge that I am aware of the risks involved from receiving sessions at this time, I voluntarily agree to assume those risks, and I release and hold harmless the trainer/business from any claims related thereto. I therefore give my consent to receive training sessions from my trainer.
Client Signature
*
Date
*
Date Format: MM slash DD slash YYYY
CONTACT US
Your Name (required)
Your Email (required)
Subject
Your Message
