Sports Therapy Consultation Form

Name

First NameLast Name

Date of birth

Date

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Format: (000) 000-0000.

Email

example@example.com

Occupation

Have you recently visited any of the following?

If yes to any of the above, please give details

Are you currently seeing another practitioner?

Main reason for attending

Is this reason a result of a specific incident or has it become apparent over a period of time?

List any medications, supplements, or herbal remedies you currently take:

Please list allergies or sensitivities:

Please list any major/recent Injuries or surgeries:

Specific aches and pains?

What is your weekly exercise routine?

Any current problem or known history of the following?

If yes to any of the above, please give details?

Myofascial dry cupping may be used as part of your treatment. This modality is painless, but can leave cupping marks on the skin that normally dissipate within 5 to 10 days. Do you consent to dry cupping being used?

I confirm that the above information is correct to the best of my knowledge. If there is a change in my condition I will notify the therapist at the earliest opportunity. I understand that this therapy may involve a combination of techniques, including physical assessment, sports massage, remedial soft tissue techniques, heat/cold applications, electro-therapy, remedial exercise and development stretching. I understand that some techniques may be uncomfortable, and some techniques may cause bruising (however the therapist will do their best to avoid this and will respond to your feedback). I understand that all treatments will be explained to me, and I give my consent to the treatment provided. I also consent to clinic administrative staff having access to this document, and agree to be contacted via telephone, email or post by administrative staff.

Signature

Date