Consultation Form

Consultation Form
Forename(s)*
Surname*
Address*
Post code*
Mobile
Home telephone
Email
example@example.com
Date of Birth*

DayMonthYear
Gender*

MaleFemale
Occupation
Name of GP or practice
GP address*
GP post code
GP telephone*
Name of any consultants or other healthcare practitioners
Medical History
How is your general health?*
What is your blood pressure reading, date and who was it taken by?*
Low/normal/high; date; GP
Are you taking any medication?*

YesNo
If ‘Yes’ name of medication, dose, is it controlling the condition and by whom was it prescribed.
Ibuprofen, 400mg, for back pain, GP
Have you had any surgery? (Date)*
Left knee replacement (2010)
Are you subject to any medical conditions?*
Diabetic Type 1
Do you have any allergies?*
Latex, Pollen
Anything else of relevance that you think I should be aware of?*
Pregnant

History of injury/condition

Current problem
Is this the first episode of the particular problem?*

YesNo
What is the problem?*
How did it occur?*
When did it occur?*
Symptoms?*
What makes the condition worse?*
What makes the condition better?*
Do you experience any ‘pins and needles’?*
Do you experience any loss of power (not due to pain)?*
Previous History of problem
Is this section relevant? (If ‘Yes’ continue with section)*

Yes, I have had this problem beforeNo, this is the first episode of problem
How did it occur?
When did it occur?
What was done about it?
Who dealt with the problem?
What were the results?
Where there any investigations?

YesNo
If ‘Yes’ what investigations, results and date.
Xray Right ankle, no break (2011)

Consent
I confirm that the above information is correct to the best of my knowledge. If there is any change in my condition I will notify the therapist at the earlist opportunity. I understand that all treatment methods will be explained to me, and I give my consent to the treatment provided.

I give consent for SRM Sports Rehabilitation & Massage to store the above details and treatment records in a computerised and hardcopy database. These details will only be used for treatment records and in the event that we need to contant you. You may withdraw your consent at any time.
Date*

DayMonthYear
Date
Signature*

Clear
Use your mouse or finger to draw your signature
Guardian’s signature

If client is 16 years or under guardian must also sign.
Guardian's Signature

Clear
Use your mouse or finger to draw your signature
Cancelation Policy

If you require to cancel or rearrange your appointment, we respectfully require 24 hour notice. This is so we can offer that appointment to others.

Cancelations or missed appointments without 24 hour notice will result in a part or full charge for the appointment.

We understand sometimes things will happen outside of your control however, we still require notice to prevent loss of time which may be allocated to others waiting.
Should be Empty:

Medical History