Online Sports Massage Consent Form

1
Name
2
Age
3
Date of Birth
Month
Day
Year
4
Gender
Please Select
Please Select
Male
Female
Other
5
Email
example@example.com
6
Contact Number
Area Code
Phone Number
7
1. Has a doctor or healthcare provider ever diagnosed you with any of the following conditions?(Check all that apply)
Please Select
Heart disease or other cardiovascular issues
High or low blood pressure
Diabetes (Type 1 or Type 2)
Respiratory conditions (e.g., asthma, COPD)
Neurological conditions (e.g., epilepsy, stroke)
Other
None of the above
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2. Do you have any unexplained chest pain or discomfort during or after physical activity?
YESNO
9
3. Have you experienced fainting, dizziness, or balance issues recently?
YESNO
10
4. Do you have any family history of heart disease, stroke, or other chronic illnesses?
YESNO
11
5. Are you currently taking any medications?
YESNO
12
6. Do you have any current or past injuries
YESNO
13
6.5. If yes, please describe (e.g., location, severity, treatment):
14
7. Do you experience recurring pain or stiffness in any of the following areas? (Check all that apply)
Please Select
Neck
Shoulders
Back (upper, mid, or lower)
Hips or pelvis
Knees
Ankles or feet
Legs ( Quads, hamstring and calves)
15
8. How much sleep do you get on average each night?
Please Select
Please Select
Less than 5 hours
5–6 hours
7–8 hours
9+ hours
16
9. Is your sleep typically:
Please Select
Please Select
Unbroken (sleeping through the night)
Broken (waking up frequently or having trouble staying asleep)
17
10. How would you describe your current stress levels?
Please Select
Please Select
Low
Moderate
High
18
11. Do you currently engage in any physical hobbies or recreational activities?
YESNO
19
11.5 If yes, please list:
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12. How would you describe your current activity level?
Please Select
Please Select
Sedentary (little to no physical activity)
Lightly active (e.g., walking, light stretching)
Moderately active (e.g., exercise 3–4 times per week)
Highly active (e.g., exercise or sports 5+ times per week)
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13. What is your current occupation, and does it involve prolonged sitting, standing, or repetitive movements?(Please describe the physical demands)
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14. Describe your Diet(include supplements)
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17. What are your primary goals for working with a Myofascial therapist?(check all that apply)
Please Select
Pain management
Injury recovery/rehabilitation
Improve sports performance
Flexibility/mobility improvement
Tension Relief
Stiff Neck
Upper, Middle and Lower Back
Shoulder Pain
Tight Hips
Knee pain / instability
Ankle and feet
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18. Are there any activities, movements, or exercises you find difficult or uncomfortable?
YESNO
25
18.5 If yes, please explain.
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Pricing All sessions 1hr
Please Select
Please Select
£50 - 1hr - King street gym members
£60 - 1hr - none - members
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Discount code
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I confirm that the information provided in this questionnaire is accurate and complete to the best of my knowledge. I understand that it is my responsibility to inform my sports therapist of any changes to my health or physical condition.
YESNO
29
Client Signature
30
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Should be Empty: