New Client Intake form For Ultractive Sports Massage

1
Section 1: Personal Details
2
Full Name* This field is required.
First Name
Last Name
3
Phone Number* This field is required.
4
E-mail* This field is required.
5
Date of Birth* This field is required.
Day
Month
Year
6
Today's date* This field is required.
Date
Day
Month
Year
7
Address* This field is required.
Street Address
Street Address Line 2
City
County
Postcode
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
8
Emergency Contact Phone Number* This field is required.Please provide the phone number of an emergency contact
9
Emergency Contact Name* This field is required.Please provide the name of an emergency contact
10
Occupation
11
Section 2: Medical Conditions
12
Please tick if you have any of the following:
Chest Pain / Palpitations / Shortness of Breath
High or Low Blood Pressure
Asthma
Skin conditions
Diebeties
Epilepsy
(Women Only) Pregnant or likey to be
Symptoms of Arthritis
Osteoporosis or other bone issues
13
Any other medical conditions not covered above, or if you need to elaborate on anything above please do so below:Please state below
Huge
Large
Normal
Small
Ok
Ok
14
MedicationsPlease describe any mediations you are on
15
AllergiesPlease describe any allergies you may have
16
Section 3: Treatment reasons
17
Tell me why you are needing a Sports Massage?* This field is required.For example, you have discomfort and pain in a particular area of the body.
18
If you are suffering from pains or niggles or discomfort please describe how long you have been suffering forPlease describe when the pain first started
19
Rate of any discomfort today
1 - very little
2 - a little
3 - painful
4 - very painful
5 - unbearable
20
Please tell me the frequency of your pain - please select the most accurate
Constant
Off/On
At Rest
With Activity
21
Is there anything that you do that creates, increases or decreases the discomfort?If yes, please explain.
22
At what time of day is the pain at its worse?
Morning
Afternoon
Evening
During Sleep
23
Have you ever had pain or discomfort in this area of the body before?
24
Have you had treatment before in this area?Please explain what sort of treatment you had and if it was effective.
25
Section 4: Lifestyle and a little bit more...
26
Have you ever received massage before?* This field is required.If yes, please describe your treatment and when this was
27
Have you ever been in an accident (car, work, falls, etc.) ?* This field is required.If yes, please explain & include dates.
28
What activities/hobbies do you enjoy?* This field is required.
29
If you are undertaking any events or competitions please state details and dates below.
Huge
Large
Normal
Small
Ok
Ok
30
Are you currently seeing any other healthcare professional for anything else?If yes, please list.
31
Anything else you would like to tell us?
Huge
Large
Normal
Small
Ok
Ok
32
Covid-19 questions* This field is required.Have you had or/and been tested positive for Coronavirus?
YESNO
33
If so please give date(s) and severity e.g no symptoms, mild, severe, hospitalised
Huge
Large
Normal
Small
Ok
Ok
34
Are you Vegan?* This field is required.I use Bee's wax so please state if you are NOT happy with me using Bee's wax and I will use Rapeseed oil instead.
YESNO
35
Are you allergic to cats* This field is required.I have one indoor cat, she may come to say hello before or after your treatment.
YESNO
36
And finally; please let me know how you found out about Ultractive Sports Massage?* This field is required.For example; running club member (please state which one), from a friend (Please include friends' name), Google, social media (Facebook, Instagram, Twitter) - Unfortunately I am unable to accept new clients who do not fill this in fully. This is for my own safety.
Huge
Large
Normal
Small
Ok
Ok

By signing with an electronic signature, I agree to the Ultractive Sports Massage terms and conditions, privacy policy and COVID-19 policy. I agree to fill in a pre-screening COVID-19 form 24 hours before my appointment.

38
Signature* This field is required.
ClearSign by using a touch tablet/screen or left click and hold as you sign with your mouse.
Should be Empty:

Save your progress

Save your progress

Your form submission has been saved as a draft.

Save your progress

Your form submission has been saved as a draft.