SMT Client Consultation Form
SECTION 1 – PERSONAL INFORMATION
Full Name
*
First Name
Last Name
What is your age?
*
Occupation
What is your gender?
*
Please Select
Male
Female
N/A
Contact Number
*
Format: (000) 000-0000.
Email Address
*
example@example.com
Emergency Contact (Name & Contact Number):
*
What is your preferred contact method?
Mobile (Calling)
Email
SMS
WhatsApp
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SECTION 2 – LIFESTYLE & MEDICAL INFORMATION
Please circle the following on a scale of 1-10 (low-high).
How manual is your job?
*
Please Select
1
2
3
4
5
6
7
8
9
10
How active are you outside of work?
*
Please Select
1
2
3
4
5
6
7
8
9
10
How stressed do you feel currently?
*
Please Select
1
2
3
4
5
6
7
8
9
10
How alert/awake do you feel currently?
*
Please Select
1
2
3
4
5
6
7
8
9
10
Please answer the following questions as accurately as you can:
How many hours sleep do you get a night? If less than 6, why?
*
Do you smoke? If yes, how many a day?
*
Do you drink alcohol? If yes, how many units per week?
*
Do you have any known allergies? If yes, please specify:
*
Have you been to the doctor in the last 6 monhts? If yes, please specify:
*
Do you have any hobbies? If yes, please specify:
*
Check the conditions that apply to you or any member of your immediate relatives:
*
Asthma
Cancer
Cardiac disease
Diabetes
Hypertension
Psychiatric disorder
Epilepsy
Strains
Sprains
Bursitis
Pregnant
Fractures
Eczema
Diabetes
Osteoarthritis
Varicose Veins
Tendonitis
Undiagnosed Lump
Deep Vein Thrombosis
Rheumatoid Arthritis
Dizziness/Double Vision
None
Other
Check the symptoms that you' re currently experiencing:
*
Chest pain
Respiratory
Cardiac disease
Cardiovascular
Hematological
Lymphatic
Neurological
Psychiatric
Gastrointestinal
Genitourinary
Weight gain
Weight loss
Musculoskeletal
None
Other
Are you currently taking any medication?
*
Yes
No
Please list them.
Do you have any medication allergies?
*
Yes
No
Not Sure
Please list them.
Do you use any kind of tobacco or have you ever used them?
*
Please Select
Yes
No
What kind of tobacco products? How long have you used/been using them?
Do you use any kind of illegal drugs or have you ever used them?
*
Please Select
Yes
No
What kind of drugs? How long have you used/been using them?
How often do you consume alcohol?
*
Daily
Weekly
Monthly
Occasionally
Never
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SECTION 3 – INFORMED CONSENT
I understand that the massage therapist is providing massage therapy services within their scope of practice as defined by The Sports Therapy Association. I hereby consent for my therapist to treat me with massage therapy for the above noted purposes including such assessments, examinations, and techniques, which may be recommended, by my therapist. I acknowledge that the therapist is not a physician and does not diagnose illness or disease or any other physical or mental disorder. I clearly understand that massage therapy is not a substitute for a medical examination. I acknowledge that no assurance or guarantee has been provided to me as to the results of the treatment. I acknowledge that with any treatment there can be risks and those risks have been explained to me and I assume those risks. I acknowledge and understand that the therapist must be fully aware of my existing medical conditions. I have completed my medical history form as provided and disclosed to the therapist all of those medical conditions affecting me. The information I have provided is trueand complete to the best of my knowledge. I have read the above noted consent and I have had the opportunity to question the contents and my therapy. By signing this form, I confirm my consent to treatment and intend this consent to cover the treatment discussed with me and such additional treatment as proposed by my therapist from time to time, to deal with my physical condition and for which I have sought treatment. I understand that at any time I may withdraw my consent and treatment will be stopped.
Explain the reason why you are booking a sports massage session.
*
Client Name
*
First Name
Last Name
Client Signature
*
Therapist Name
First Name
Last Name
Therapist Signature
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