Full Name
*
First Name
Last Name
Gender
*
Male
Female
Non-binary
Date of Birth
*
Address
*
Street Address
Street Address Line 2
City
State/ Province
Post Code
Email
*
Mobile Number
*
What is your occupation and your working hours?
*
If applicable, include details on flexi-days or hybrid work schedules.
Emergency Contact
*
Contact Name
Relationship
Contact Number
State / Province
Postal / Zip Code
How did you hear about us?
*
Google/Instagram/Facebook/A friend
Registered GP Practice
*
Do you see a chiropractor, physio or osteopath?
*
Are you currently taking any medication?
*
Have you experienced or are experiencing any blood/health conditions?
*
Do you have any underlying blood related conditions? (e.g. high blood pressure/anaemia etc.)
*
Yes
No
If yes, please state below
Other
Are you currently pregnant?
*
Yes
No
Please detail any past and recent injuries? (e.g. stress fractures, ankle sprains, ACL tear)
*
Is there anything else about your health/medical history that you think would be useful and important for your sports massage practitioner to know to plan a safe and effective massage session for you?
*
E.g. high blood pressure, arthritis, birth control pills etc.
Please detail (if you can) how your injury occurred
*
Do you have any allergies/sensitivities?
*
Have you had a sports/deep tissue massage before?
*
Yes
No
What pressure do you prefer?
*
Light
Medium
Deep
What appointment are you looking to book?
*
Sports Massage Only
Dry Cupping Only
Assisted Stretching
Mixed
If you are a female enquiring for Dry Cupping Therapy, please note that you would need to book a time when you are not due to be menstruating.
Got it!
Are you experiencing any of the following?
*
Muscle tension
Anxiety
Trouble sleeping
Irritability
Other
Do you sit/stand for long hours?
*
Yes
No
Do you have any hobbies or sports that you regularly do?
*
Are you training for any sporting events? If yes, please give details including date of the events.
*
Is there a particular area of the body where you are experiencing tension, stiffness, pain or other discomfort?
*
Head
Neck
Shoulders
Arms
Upper back
Mid back
Lower back
Hips
Glutes
Quads
Hamstrings
Calves
Feet
Other
Do you have a gift voucher? If yes, please provide the voucher code in the box below.
*
Yes
No
Voucher Code
With your details provided above, how would you like us to get back to you? (Please allow 24 hours)
*
Email (might end up in your junk/spam mail)
WhatsApp
Text Message
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