Sports Massage Pre-Treatment Questionnaire Sports Massage Pre-Treatment Questionnaire Full name * Email * Address * DOB * Phone * Occupation Reason(s) for Seeking Therapy Today Please list any previous or current treatments or medication for your condition: Do you have tension or soreness in a specific area? (Pain/Stiffness/Numbness/Tingling) Do you frequently suffer from stress? Yes No Do you have diabetes? Yes No Have you experienced frequent headaches? Yes No Are you pregnant? Yes No Do you suffer from arthritis? Yes No Do you have high blood pressure? Yes No Are you taking any medications? Yes No Do you suffer from epilepsy or seizures? Yes No Do you suffer from joint swelling? Yes No Do you have varicose veins? Yes No Do you have any contagious diseases Yes No Do you have osteoporosis? Yes No Do you have any allergies? Yes No Do you bruise easily? Yes No Have you been in an accident or suffered any injuries in the past two years? Yes No Do you have any scars (regardless of how old) on your body anywhere? Yes No Do you have tension or soreness in a specific area? Yes No Please specify Do you have cardiac or circulatory problems? Yes No Do you suffer from back pain? Yes No Do you have numbness or stabbing pains anywhere? Yes No Are you sensitive to touch or pressure on any area of your body? Yes No Have you ever had surgery? Yes No If you answered YES to any questions, please give FULL DETAILS below: Please confirm: Please tick here to show you accept and understand below: • In accordance with the new GDPR regulations of May 2018 clients have the right to request to see any personal data that Movement-for-life have on record. This data is held for insurance and medical purposes and is never given to any third-party organisation. • Clients recognise that technology is a powerful tool within marketing and sharing amazing results with members of the public. Therefore, clients are sometimes in photography, filming and social media. Unless otherwise informed, movement-for-life has permission to display media such as, photos and videos or clients on face book/website and other marketing sources. • Clients understand that any comment they say/write/film can be used as a testimonial to promote movement-for-life. This includes photos as well. Submit
