Sports Massage Consultation Form

Sports Massage Consultation Form
Client Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Sex*

FemaleMale
Date of Birth*

DayMonthYear
Date
Number of Children (If Applicable)
Age Group*

Under 2020-3030-4040-5050-6060+
Current Activity Levels

ActiveSedentary
Last visit to Doctor*

DayMonthYear
Date
Contraindications (Please tick where appropriate) Never treat unless the injury has been diagnosed and treatment has been recommended by a medical practitioner.

PregnancyCardio vascular conditions (thrombosis, phlebitis, hypertension, hypotension, heart conditions)HaemophiliaAny condition already being treated by a GP or another health professional, e.g. Physiotherapist, Osteopath, Chiropractor, CoachMedical oedemaOsteoporosisArthritisNervous/Psychotic conditionsEpilepsyRecent operationsDiabetesAsthmaAny dysfunction of the nervous system (e.g. Muscular sclerosis, Parkinson’s disease, Motor neurone disease)Bells PalsyTrapped/Pinched nerve (e.g. sciatica)Inflamed nerveCancerPostural deformitiesDysfunctions of the nervous systems (e.g. cerebral palsy/sroke/ Multiple sclerosisKidney infectionsWhiplashSlipped discUndiagnosed painWhen taking prescribed medicationAcute rheumatism
Contraindications that restrict treatment (Please tick where appropriate)

FeverContagious or infectious diseaseUnder the influence of recreational drugs and/or alcoholDiarrhea or vomitingSkin diseasesUndiagnosed lumps or swellingsLocalised SwellingInflammationVaricose veinsPregnancy (abdomen)CutsBruisesAbraisonsScar tissues (2 years for major operation and 6 months for a small scar)SunburnHormonal implantsAbdomen (first few days of menstruation depending how the client feels)HaematomaHemiaRecent fractures (minimum 3 months)Cervical spondylitisGastric ulcersAfter a heavy meal
Written permission required by Specialist

YesNo
Personal Information

Please tick or answer where appropriate
Muscular/skeletal problems

BackAches/painsStiff jointsHeadaches
Digestive Problems

ConstipationBloatingLiver/Gall bladderStomach
Circulation

HeartBlood pressureFluid retentionTired LegsVaricose VeinsCelluliteKidney problemsCold hands and feet
Gynaecological

Irregular periodsPMTMenopauseHRTPillCoil
Nervous System

MigraineTensionStressDepression
Immune System

Prone to infectionsSore throatsColdsChestSinuses
List any Antibiotics/Medication taken
Sleep quality

GoodPoor
How many hours a day do you work at a computer?
Do you eat regular meals?

YesNo
Do you exercise? If so how many times per week?
What is your skin type?

DryOilyCombinationSensitiveDehydrated
Sport Details
What sports/activities do you participate in?
How long have you been doing this?
How often do you play/train per week
Please list any injuries sustained whilst participating in your sport or activity.
Disclaimer Form

Please read the following and tick the appropriate box, by ticking the box you are confirming you are in full agreement with the statements contents.
Client Information*

I confirm that I have understood the treatment that I am going to receive. I also confirm that I am willing to proceed without confirmation from my own G.P or Consultant.I confirm that I have understood the treatment and given my medical history I would prefer to consult with my GP or Consultant prior to receiving the treatment.
Client Full Name*
Signature

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Signature
Date

DayMonthYear
Date
Parental Consent (Where Applicable)

To be completed by Parent or Guardian if client is under the age of 18.
By signing below, you agree that you are the parent or legal guardian of the minor receiving treatment(s) and consenting to the treatment recommended by the therapist. You understand that you are required to remain at the facility for the entirety of the minor’s treatment(s). You will also be required, if needed, to assist the minor in preparing for his/her treatment(s). We also request that you remain in the treatment room to supervise all interactions between the therapist and the minor.You also agree that you have completed the Consultation Form and have informed the therapist of all medical diagnoses, symptoms, medications, and complaints associated with the minor receiving treatment(s).

I Agree
Parent/Guardians Full Name
Signature

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Date

DayMonthYear
Date
Should be Empty:

Sports Massage Consultation Form

Personal Information

Sport Details

Disclaimer Form

Parental Consent (Where Applicable)