Pre-Appointment Consultation Form
Please complete this form prior to your appointment to help us provide you with the best possible care.
Personal Information
Full Name
*
First Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
Date
Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Gender
*
Female
Male
Other
Occupation (What do you do for work?)
Emergency Contact Name
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to You
*
GP's Surgery Contact Name
GP's Surgery Email or Phone Number
Medical Information
Do you have any medical conditions?
*
Yes
No
If yes, please specify any relevant conditions.
Have you had any surgeries or injuries?
*
Yes
No
If yes, please specify your surgeries or injuries.
Are you currently taking any medication?
*
Yes
No
If yes, please specify your medication.
Contraindications Screening
Do you currently have any of the following?
*
Fever
Infection
Open wounds
Skin rashes
Skin Conditions (Psoriasis/Eczema etc)
Recent fractures
Blood clots
Heart conditions
High or low blood pressure
Cancer
Deep vein thrombosis
Varicose veins
Recent surgery
Cold/Flu
Strains
Sprains
Allergies
None of the above
Please use the space below to provide any additional information, concerns, or conditions that you feel may be relevant to your treatment
Main Problem and Reason for Visit
What brings you in for treatment?
*
Where is your pain or discomfort? (Please specify locations)
*
When did it start?
*
Does this affect your daily activities? (e.g., walking, sitting, sleeping, holding items)
What makes it worse and what makes it better?
Does the pain travel or radiate anywhere? (e.g., down the leg or arm)
On a scale of 0-10, rate your pain
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst pain
10
0 is No pain, 10 is Worst pain
Pain description
Sharp
Dull
Aching
Burning
Tingling
Not sure
Lifestyle Activity Level
Low
Moderate
High
What type of Hobbies or interests do you participate in
Have you had massage or therapy before?
Yes
No
If yes, What type and did it help?
Expectations (What would you like to get out of this session? Anything else to know before your session?)
During your treatment, would you like a quiet session (only essential communication), or do you prefer light conversation?
Quiet Session
Light Conversation
Fine Either Way
Photo and Media Consent
From time to time, I may take photographs or short videos for marketing, educational, or promotional purposes (such as social media, websites, or booking platforms). Please tick one option below.
YES, I give consent for photographs/videos to be taken and used for marketing or promotional purposes.
YES, ANONYMOUSLY. I consent to photographs/videos where my face and identifying features are not visible to be used for marketing or promotional purposes.
NO, I do not give consent for photographs or videos to be taken
Acknowledgement of Terms & Conditions
Todays Date
Signature
Submit Consultation
Submit Consultation
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