Full Name
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First Name
Last Name
Gender
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Male
Female
Non-binary
Date of Birth
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Address
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Street Address
Street Address Line 2
City
State/ Province
Post Code
Email
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Mobile Number
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Occupation?
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Emergency Contact
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Contact Name
Relationship
Contact Number
State / Province
Postal / Zip Code
How did you hear about us?
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Google/Instagram/Facebook/A friend
Registered GP Practice
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Do you see a chiropractor, physio or osteopath?
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Are you currently taking any medication?
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Have you experienced or are experiencing any blood/health conditions?
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Do you have any underlying blood related conditions? (e.g. high blood pressure/anaemia etc.)
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Yes
No
If yes, please state below
Other
Are you currently pregnant?
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Yes
No
Please detail any past and recent injuries? (e.g. stress fractures, ankle sprains, ACL tear)
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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?
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E.g. high blood pressure, arthritis, birth control pills etc.
Please detail (if you can) how your injury occurred
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Have you had a sports/deep tissue massage before?
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Yes
No
What pressure do you prefer?
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Light
Medium
Deep
What appointment are you looking to book?
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Sports Massage Only
Dry Cupping Only
Both
Do you have any allergies/sensitivities?
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Are you experiencing any of the following?
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Muscle tension
Anxiety
Trouble sleeping
Irritability
Other
Do you sit/stand for long hours?
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Yes
No
Do you have any hobbies or sports that you regularly do?
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Are you training for any sporting events? If yes, please give details including date of the events.
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Is there a particular area of the body where you are experiencing tension, stiffness, pain or other discomfort?
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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.
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Yes
No
Voucher Code
I will aim to get back to you within 24 hours. Please keep an eye on your junk mails just incase!
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