Personal DetailsThis form is strictly confidential and will not be shared with anyone without your permission.Name(Required) First Last Email(Required) Contact Number(Required)Date Of Birth DD slash MM slash YYYY Full Address inc PostcodeCurrent OccupationDo you take part in any sport activity? Yes No If yes please give details belowDetailsMedical HistoryDo you have, or have you had in the past 6 months, any of the following symptoms/conditions? NONE Cardiovascular Disease Diabetes ( if not fully controlled) Epilepsy Disorders of the nervous system Disorders of the lymphatic system Auto Immune Disorders HIV/AIDS Thrombosis (DVT) Neural Disorder Pneumonia Rheumatoid Arthritis Cancer Select AllIf you have any of the above, a GP letter will be required to continue with your appointment.Please tick if relevant NONE Pregnancy Diabetes ( client fully controlled) Haemophilia Severe hypertension/ hypotension (if client controlled) Asthma Headaches Sinusitis Inflammation Fractures Sprain or Strain Recent operations Medically weak tissue, bone or skin Select AllHave you had to visit your GP in the last 6 months? Yes No If yes please give details belowDetailsAre you on prescribed medication? Yes No If yes please give details belowDetailsAre you receiving treatment from any other healthcare professional? Yes No If yes please give details belowDetailsDo you have any allergies Yes No If yes please give details belowDetailsName of your GP practicePlease describe your current symptoms or reason for your appointment?Winter Flu / ColdPlease note: If you are due to receive a Covid-19 or Flu jab, please allow 48hrs prior to your massage treatment. Are you currently taking medication for Winter Flu?(Required) Yes No If you have answered Yes, treatment can proceed once GP approval has been granted.Have you or any of your household been contacted by the Test and Trace Team and advised to self-isolate?(Required) Yes No If yes, the treatment can only take place once the period of self-isolation has been completed.If you or any member of your household currently have any symptoms of Winter Flu then please postpone your appointment. Treatment can commence once you are symptom free.CAPTCHA Δ
