Massage/Exercise form

Name

First NameLast Name

Email

example@example.com

Phone Number

Area CodePhone Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal Code

What is your occupation?

Have you or anyone in your household been advised by the Government to be clinically vulnerable and to shield?

Have you or anyone in your household ever been diagnosed with Covid 19?

Have you or anyone in your household shown any symptoms of Covid 19 in the last 7 days?

Have you recently travelled abroad? If yes, where to and when did you return?

Have you noticed any new rashes to your body or feet?

Please tick to confirm you will notify me if you or anyone in your household develop symptoms associated with Covid 19

If anything changes between now and your appointment date, please contact me asap. Please tick to confirm you have read this and will do so

have you had any unusual leg cramping?

Please contact me if anything changes between now and your appointment date if your health changes in anyway. Please tick to confirm you have read this and agree to it

Are you seeing or have you seen any other professionals at all? (Chiro, osteo, GP, midwife)

Type a question

Details of anything ticked above

Is there anything else you think I should know?

Has your doctor ever advised you that you have a heart condition?

Are you undertaking any forms of exercise? If yes, what?

How would you rate your stress levels out of 10? 10 being very stressed

How would you rate your emotional health out of 10? 10 feeling very emotional

How would you rate your fitness levels out of 10? 10 being very fit

Informed consent

I declare that the information I have given is correct, and as far as I am aware I can undertake this treatment/session. I also confirm that I have not withheld any information which maybe relevant to my undergoing any treatment/Exercise.

Exercise

Please consult your GP or women’s health physiotherapist before you embark on any exercise. Drink lots of water or an isotonic drink before, during and after working out. Please wear comfortable clothing that will enable you to exercise without restrictions.

Massage

I will inform Tanya if there is anything I don’t feel happy with or I find uncomfortable.

Informed consent

I would like to be placed on the emailing list for the newsletter and updates and offers