Pre Appointment Sports Massage Forms Sports Massage Client Intake form Sports Massage Client Intake Form Name * First Name Last Name Email * Reason For Your Visit * Please outline the key reason(s) for your appointment (e.g. specific injury; general recovery etc) and what the goals are of your treatment. Medical Information (All information is strictly confidential). Are you taking any medications? Yes No If yes, please list name and use: Are you currently pregnant? Yes No If yes, how far along & please specify any high risk factors: Do you suffer from chronic pain? Yes No If yes, please explain. What makes it better? What makes it worse? Have you had any orthopedic injuries? Yes No If yes, please list: Please indicate any of the following that apply to you: Cancer Headaches/Migraines Arthritis Diabetes Joint Replacement High Blood Pressure Low Blood Pressure Neuropathy Fibromyalgia Stroke Heart Attack Kidney Dysfunction Blood Clots Numbness Sprains or Strains Provide further details of any conditions marked above: MASSAGE INFORMATION Have you had a professional sports massage before? Yes No What pressure do you prefer? Light Moderate Deep Do you have any allergies or sensitivities? Yes No If yes, please detail here: Are there any areas you do not want to be massaged? (e.g. feet, neck etc.) Yes No If yes, please detail here: Please indicate below whether you agree to the following: * I have competed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at any time. Yes No Thank you! Pregnancy Massage Client intake Form Pregnancy Massage Client Intake Form Name * First Name Last Name Email * Date of Birth MM DD YYYY How many weeks pregnant are you? * When is your due date? * MM DD YYYY Is this your first pregnancy? * Yes No If not, how old is/are your previous children? * Do you have consent from your GP/midwife to have a pregnancy massage? Yes No How has your current pregnancy been? Please include any medical comments, if relevant. * Are there any pre-existing health conditions to be aware of? * Please list and ailments you may be suffering from. For example: backache, anxiety, SPD, heartburn etc. * Are you currently under obstetric care? * Yes No If yes, please state why. * How would you describe your overall well being taking into account your physical, mental and emotional state? * What date was your last check -up with a midwife or GP? * MM DD YYYY Were there any comments/actions following this last check-up? * Are you taking any medication? * Have you had any recent operations (including C-section)? Please state the date of operation if applicable. * Have you suffered from, or are currently suffering from any of the following symptoms? Please tick to indicate 'Yes'. Chest Pain Palpitations High Blood Pressure Low Blood Pressure Asthma Shortness of Breath Nausea Reflux Sciatica Separation of the Symphysis Pubis Carpal Tunnel Syndrome Problems with the Placenta Leg Cramps Anemia Bladder Infection Uterine Bleeding * Any other conditions or problems in your current or previous pregnancies? Is there any reason (medical or otherwise) why you think you should not be able to have a pregnancy massage? Yes No I have competed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at any time. Yes No * Client Signature/Initials & Date. Thank you!
