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CONSULTATION FORM

Please fill out all of the below questions, prior to your appointment.

First Name

Last Name

Email Address

Client Address:

Telephone Number

Occupation

Sex

Date of Birth

GP Address

Contraindications (please tick where appropriate)
Never treat unless the injury has been diagnosed and treatment has been recommedned by a medical practitioner.

Pregnancy

Cardio Vascular Conditions (thrombosis, phlebitis, hypertension, hypotension, heart conditions)

Osteoporosis

Haemophilia

Any condition already being treated by a GP or another health professional, e.g. Phsyiotherapist, Ostepath, Chiropractor, Coach

Medical Oedema

Arthritis

Nervous / Phychotic Conditions

Epilepsy

Any recent operations

Diabetes

Asthma

Any dysfunction of the nervous system (e.g. Muscular scelrosis, Parkinson's Disease, Motor Neurone Disease

Kidney Infections

Whiplash

Slipped Disc

Acute Rheumatism

Taking prescribed medication

Contraindications that restrict treatment (please tick where appropriate)

Fever

Contagious or Infectious disease

Under the influence of recreational drugs and/or alcohol

Diarrhea or vomiting

Skin Diseases

Undiagnosed lumps or swellings

Localised swelling

Inflammation

Varicose Veins

Pregnancy

Cuts

Abrasions

Sunburn

Scar tissues (2 years for major operations & 6 months for small scar)

Hormonal Implants

Abdomen (first few days of menstruation depending on client)

Haematoma

Hernia

Recent fractures (min 3 months)

Cervical Spondylitis

Gastric Ulcers

After a heavy meal

Bruises

Written permission required by GP/Specialist (Seperate form to be collected)

Personal Information

Please tick or answer where appropriate

Muscular / Skeletal Problems:

Back

Aches / Pains

Stiff Joints

Headaches

Digestive Problems:

Constipation

Bloating

Liver/Gall Bladder

Stomach

Circulation:

Heart

Blood Pressure

Fluid Retention

Tired Legs

Varicose Veins

Cellulite

Kidney Problems

Cold Hands and Feet

Nervous System:

Migraine

Tension

Stress

Depression

List any antibiotics / medication you are taking:

List any herbal remedies you are taking:

How many hours a week do you spend working on a computer?

Please list any allergies including any skin allergies that could be caused by massage oil, cream or wax:

Do you exercise? How many times a week?

Right or Left Handed?

Sports Details

Please tick or answer where appropriate

What sports / activities do you participate in?

How long have you been doing these?

At what level do you participate?

Recreational

Club

International

Regional / County Level

National

OTHER

How many days a week do you train in these?

What is your preffered position / discipline / distance within your sport?

Please list any injuries sustained whilst participating in your sport or activity

DISCLAIMER

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 consent to full treatment by NW Sports Massage Therapy which can include any of the following: Joint adjustment or manipulation or mobilisation to the joints of my spine (neck and back), pelvis and extremities (shoulder, upper limbs and lower limbs), Cupping Therapy, IASTM Therapy, The use of a hand held Massage Gun and Full body Sports Massage Therapy. This consent applies to all my present and future treatments at NW Sports Massage

Please tick this box if you are happy for any photographic or video content pre, during or post treatment to be shared and used for promotional purposes

Parental Consent:

By ticking this box, you agree that you are the parent or legal guardian of a minor receiving treatment(s) and consenting to the treatment performed by the therapist. You understand that you are required to remain at the facility for the entirety of the minors treatment(s). You will also be required, if needed to assist with the minor in preparing for his/her treatment(s). We also request that you remain in the treatment room to supervist 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, symptons, medications and complaints associated with the minor receiving treatment.

Full name of minor receiving treatment

Parent/Guardians Full Name

You should note that if the therapist is unable to explain to you the contraindications or is unsure of anything that may apply to a specific condition then they should not treat you without asking you to consult with your GP or Consultant. It is your responsibility and not that of the therapist to consult your GP or Consultant. *

Please type your name as part of your consent for the above consultation form:*

Please type todays date as part of your consent for the above consultation form:*

Thank you for completing your consultaion form.

Opening Hours

Monday - 11am - 5pm

Tuesday - 12pm - 7pm

Wednesday - 12pm - 7pm

Thursday - 12pm - 7pm

Friday - 12pm - 5pm

Saturday: 9am – 1pm

Sunday: Closed. (Emergency appointments only)

Requests for specific times & days can be arranged.

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Contact Us

Mail: info@nwsportsmassagetherapy.co.uk
Tel: 07562182888

Broughton, MILTON KEYNES

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