Lion Sports Therapy & Rehabilitation Patient Consultation Form

Name

First NameLast Name

Age

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

Email

example@example.com

Any past illnesses?

Any recent surgery?

Have you been admitted to hospital recently?

Are you on any medication, steroids, supplements, homeopathic remedies etc?

Please indicate the injury zone?

ABCD

Any specific information related to the injury?

Is the pain: Numb/Dull Ache/Burning/Sharp Stabbing/Pins Needles/Other

What is the degree of pain (0 being none and 10 being severe):

What does pain INCREASE with?

What does pain DECREASE with?

Does the pain effect your sleep? If so, briefly describe how:

Have you been to see anyone about THIS injury/pain? If so, what did they find/do?

What manual therapy have you had in the past? i.e. sports massage, cupping, manipulation, ultrasound therapy etc.

Any additional information?

Which venue are you seeing Lion Sports Therapy at?

The Warehouse Gym (22-24 Lunsford Road, LE5 0HJ)Evolution Fitness (15 Mandervell Road, LE2 5LQ)Other

I understand that before each treatment visit, I will inform Lion Sports Therapy & Rehabilitation if I am experiencing any Covid-19 or flu related symptoms, with at least 24 hours notice. If not, I agree I can be turned away from the treatment and required to pay the full session amount.

YesNo

I understand that a 24 hour notice prior to my appointment is required, if I am unable to attend the appointment. However, if I cancel on the day of the appointment, I understand that I am required to pay the full amount of the session (see T&C's for full information).

YesNo

Terms, Conditions and Consent to Treatment (patient to read and sign).

I agree to undertake Sport Therapy treatment, as deemed necessary, after assessment and discussion with Jazz Singh (Sports Therapist).
I am aware I have the right to see my treatment records and these will not be released to any person without my written consent.
I have been informed that I may be accompanied during all treatments.
I understand that all treatments will be explained to me.
Some forms of treatment are regarded as uncomfortable however, I remain in control and can stop treatment at any time.
I declare that the information provided is correct to the best of my knowledge, and will notify the therapist of any changes in my medical condition as soon as I am aware of it.

Signature

Date

Patient Consultation Form

History