Client Details
This form is of substantial length; however, it is important to bear in mind that its purpose is to facilitate the optimal provision of care for you. Please be assured that any data you provide will be handled with the utmost discretion and confidentiality.
Name
*
First Name
Last Name
Gender
*
Male
Female
Prefer not to say
Address
*
Street Address
Street Address Line 2
City
State / Province
Postcode
Phone Number (mobile preferred)
*
Do NOT include spaces
Email
example@example.com
Date of birth
*
/
Day
/
Month
Year
minimum age of 14 yrs
Name of Emergency Contact
*
First Name
Last Name
Emergency contact Phone Number (mobile preferred)
*
Do NOT include spaces
Will this be your first sports massage?
*
Yes
No
When was your last sports massage?
Back
Next
Medical information
GP Practice and address
*
Street Address
Street Address Line 2
City
State / Province
Postcode
Are you currently taking any prescribed medication?
*
Yes
No
Please add/list your medication here
*
If you're not taking any medication please add 'Not Applicable'
Have you recently (in the last 12 months) suffered from any significant illnesses?
*
Yes
No
Please add more detail on the illnesses you have had over the last 12 months
*
Please be assured that any information provided in this form will be treated with the utmost confidentiality, and the data you share will be subject to encryption measures.
Is there a possibility you could be pregnant?
*
Yes
No
Current Exercise/Activities (frequency, type, how much, intensity):
Lifestyle stressors
e.g. work-related stress, financial stress
Have you suffered or are you suffering from any of the following?
*
Skin disorders (dermatitis, eczema, sensitivity, fungal injections)
Muscular or skeletal problems (fibromyalgia, previous fractures)
Neurological problems (sciatica, epilepsy, migraine)
Urinary problems (cystitis, thrush, kidney problems)
Immune system (prone to colds, reduced immune status)
Gynaecological problems (PMT, menopause, HRT, irregular periods)
Hormonal problems (diabetes)
Digestive problems (indigestion, constipation, IBS)
Stress-Related or psychological problems (depression, anxiety, panic attacks, mood swings)
Circulation issues (heart, lungs, swelling, blood pressure)
Urinary problems (cystitis, thrush, kidney problems)
None of the above
Other
Back
Next
Your reason for a sports massage
A sports massage primarily helps to enhance athletic performance, alleviate muscle soreness, and prevent injuries by promoting flexibility and circulation in targeted muscle groups.
Are you seeking a standard sports massage without targeting a specific area?
*
Yes
No
Massage Treatment - Expectations
*
What do you hope to get out of your massage treatments – short and long term?
Please select the area you are experiencing pain or discomfort.
Neck
Upper back
Lower/Middle Back
Glute(s)
Hamstrings
Achilles/Feet
Shoulder(s)
Arm(s)
Quadriceps
Calves
When did the pain you are experiencing begin?
Have you received prior treatment for this condition, and was it effective?
Can you describe the type of discomfort you are feeling? What is the severity on a scale of 1-10?
Do you know what caused your pain?
Have you had any previous injuries to the same area?
How does this condition affect your work and leisure?
Client Assessment - Informed consent to examination
*
I affirm the accuracy of the information provided in this form, recognising its significance for my therapy safety. I also acknowledge the necessity of a pre-treatment physical assessment, which has been explained to me, and I am fully willing to proceed. Furthermore, I take responsibility for the accuracy of my treatment-related information and commit to informing my therapist of any changes.
Submit
Should be Empty: