Consultation Form - Sue Savage Sports & Remedial Massage

Date(Required)

DD slash MM slash YYYY

Name(Required)

First Last

Phone(Required)

Email(Required)

Address(Required)

Street Address Town/City Post Code

Date of Birth(Required)

DD slash MM slash YYYY

Occupation(Required)

Height (M)(Required)

Weight (KG)(Required)

Medications 0r Medical Procedures Within The Last 12 Months(Required)

Please describe what the procedure was. If you aren't taking any medication, please state NONE.

Gender(Required)

Any current problems or history of the following:

Pace-maker

Joint replacement/Pins and plates

Respiratory conditions

Recent Fracture/Sprain/Strain

Nervous dysfunction/muscular spasticity

Recent haemorrhage

Cardiovascular conditions

Undergoing chemo or radiotherapy

Thrombosis / Embolism / Varicose veins

Circulatory / blood pressure problems

Diabetes

Epilepsy

Currently pregnant

Skin Disorders

Allergic conditions

Recent Surgery or major illness

Any other medical conditions?(Required)

If yes, please list details:

GP consent required:(Required)

If yes, Doctor's name and surgery

General Lifestyle(Required)

Level of Life Stress(Required)

Please enter a number from 1 to 10.

On a scale of 1-10, 1 being the lowest.

Level of exercise / physical activity / training(Required)

Workplace Activity(Required)

Please describe physical activity undertaken at work

Have You Had An Alcoholic Drink Within The Last 12hrs(Required)

Site & spread of complaint(Required)

Where does it hurt and what area does it cover.

Behaviour of symptoms(Required)

What is the problem e.g. I cannot move my arm above my head.

Onset & duration(Required)

When does it occur and how long does it typically last for.

Have you any symptoms of covid, or any other virus related symptoms recently or within the last 14 days?(Required)

Are you seeing or waiting to visit a Medical Practitioner/Doctor/Specialist?(Required)

Consent(Required)

Confirm

To the best of my knowledge, all information given is correct and I understand that I must inform my therapist of changes to my health during treatment.

Disclaimer(Required)

Confirm

I accept that any false information provided is my own responsbility and the therapist cannot be held accountable.

DATA SECURITY: Please note that we do not share your information with any third parties. It is only used by Sue in order to customise the treatment to suit your specific needs.

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