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Sports Massage Consultation Form
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Email
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Your email
Name
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Your answer
Date Of Birth
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MM
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DD
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YYYY
Phone Number
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Your answer
Home Address
Your answer
Occupation
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Your answer
How manual is your job?
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Completely sedentary
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Non-stop active
How active are you outside of work?
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Not at all
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Extremely
How stressed do you feel currently?
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Not at all
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10
Chronically stressed
How many hours sleep do you get a night? And what is the quality of it? If less than 6, why?
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Your answer
Do you smoke? If so, how much?
Your answer
Do you drink alcohol? If yes, how much a week?
Your answer
Do you have any known allergies? If yes, please specify
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Your answer
Have you been to a doctor in the last 6 months? If yes, please specify
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Your answer
Have you had surgery in the last 10 years? If yes, please specify
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Your answer
What are your hobbies?
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Your answer
If you have a current exercise regime, please detail what exercise you do, how long for and how often
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Your answer
Have you previously had, or do you currently have any of the following:
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Strains
Sprains
Asthma
Bursitis
Pregnancy
Fractures
Eczema
Diabetes
Epilepsy
Cancer
Osteoarthritis
Varicose Veins
Tendonitis
Undiagnosed Lump
Deep Vein Thrombosis
Rheumatoid Arthritis
Dizziness/Double Vision
Cardiovascular Disease
Other Injury
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If you ticked any of the above, please give details below
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Your answer
Please detail specifics on what you would like treatment for? E.g For muscle tightness or pain, where in your body, how long had for, if cause is known, if anything makes it worse, how it's impacting your lifestyle or performance
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Anything else I need to know?
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