Intake form: Health Questionnaire

Deborah Wilks

Fascia Stretching Health Questionnaire
Full name*

First NameLast Name
Date of Birth*
Phone number*
E-mail*
Address
Emergency contact*

First NameLast Name
Phone number*
GPs name*

First NameLast Name
GP Surgery Address*
I give my consent for my notes to be shared with my GP*

YesNo
Client information - Health questionnaire (Par-Q)
Main issues/focus for treatment*
Have you ever had a major operation? If so please give details *
Are you currently taking any medication? If so please give details *

Do you or have you suffered from any of the conditions below?*

	Yes	No
Epilepsy
Migraines
Spinal or other fractures
Bladder problems
Asthma
Heart condition
Osteoperosis
Skin Conditions
Diabetes
Joint problems
Cancer
High Blood pressure
Varicose veins
Other

If you have answered 'YES' to any of the above, please give details
Goal for the session
Are you pregnant, or have you been pregnant within the last year?

YesNo
I have read, understood and completed this questionnaire. I understand that stretching sessions may lead to some muscle soreness for a few days after treatment.

All the information I have given above is correct to the best of my knowledge.
Signed
Date
Should be Empty: