0
Items :
0
Subtotal :
£
0.00
View Cart
Check Out
Home
Personal Training
Online Training
Buddy Up/Partner Training
Par Q form
Covid19 Information
Sports Massage
Consultation Form
Prep Coaching
Experience
Competitive History
Qualifications
Transformations Gallery
Home Workouts
Photo Shoots
Agreement Form
Entry Form
Information Sheet
Contact
Home
Personal Training
Online Training
Buddy Up/Partner Training
Par Q form
Covid19 Information
Sports Massage
Consultation Form
Prep Coaching
Experience
Competitive History
Qualifications
Transformations Gallery
Home Workouts
Photo Shoots
Agreement Form
Entry Form
Information Sheet
Contact
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
We use cookies to ensure that we give you the best experience on our website. If you continue to use this site we will assume that you are happy with it.
Ok
Okay, thanks
