Client Assessment

Reason for visit:

Client hopes and expectations of treatment:

Date of Treatment

Client Details:

Name(Required)

Prefix First Last

Address

Address Line 2 City County Postcode Country

Phone(Required)

Email(Required)

Occupation:

GP Practice:

I am:

General health:

How would you describe your general health?(Required)

Medication

Are you taking any medication?(Required)

If Yes please provide details in box below:

Medication details:

Please provide details

Surgery

Have you had any recent surgery in the past 18 months?(Required)

If Yes please provide details in box below:

Surgery details:

Physical Activity

How would you describe your level of physical activity?(Required)

This includes walking and gardening

Previous Treatment/s

Have you had Sports Massage, Physiotherapy, Osteopathy or Chiropractic treatment before?(Required)

If so, when and please provide brief details.

Stress Levels & Energy

How would you rate your current level of stress at the moment?(Required)

How would you describe your energy level today?(Required)

Sleep

Are you having difficulty sleeping at the moment?(Required)

Hours of sleep per night:(Required)

Other relevant information

Anything else of relevance that you think I need to be aware of?

Client Consent

I have understood the questions asked above. To the best of my knowledge the answers given are correct and I give consent for treatment.

Name(Required)

Prefix First Last

Date

GDPR Privacy Permission*(Required)

Please tick the box to agree to the storage and handling of your data by this website. Information is sent encrypted via a secure connection and only you and Exeter Sports Massage will receive a copy via email of the information supplied.

I agree to the storage and handling of my data by this website.

Client Assessment