Sports Massage & Dry Cupping Therapy Form

Full Name

First NameLast Name

Gender

Date of Birth

Address

Street Address

Street Address Line 2

City

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

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.)

Other

Are you currently pregnant?

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?

What pressure do you prefer?

What appointment are you looking to book?

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.

Are you experiencing any of the following?

Do you sit/stand for long hours?

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?

Do you have a gift voucher? If yes, please provide the voucher code in the box below.

Voucher Code

With your details provided above, how would you like us to get back to you? (Please allow 24 hours)