Sports Therapy Consultation Form

Sports Therapy Consultation Form
Name*

First NameLast Name
Date of birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Email*
example@example.com
Occupation
Have you recently visited any of the following?

DoctorConsultantPhysiotherapistOsteopathSports TherapistChiropractorMassage TherapistAcupuncturistOther
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?

HeadLower backHandsNeckHipsLegsUpper backArmsFeet
What is your weekly exercise routine?
Any current problem or known history of the following?*

Musculo-skeletal problemCuts, bruises, burns, rashes, scars, warts or molesBreech birthPregnancies, caesarian sectionsArthritis, osteoporosis, fractures, joint replacements, pins or platesDigestive, urinary, endocrine, respiratory, neurological problemsHeart, circulatory, arterial, blood pressureThrombosis, embolism, varicose veinsDiabetes, epilepsy, asthmaSkin conditionsNone
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?

YesNo
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*

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