Pre-massage Questionnaire | Sports Massage by Jenny Allan

PRE-VISIT QUESTIONNAIRE

This questionnaire should be completed only when requested - once an appointment has been made, and in advance of the visit.

It ensures that I am able to tailor the session to your needs and that any contraindications are declared. These are listed in full below. All datapoints submitted are kept entirely confidential.

*Required field

Name *

Contact details *

Emergency contact name & contact details

Summary of relevant lifestyle details - eg sedentary / physical occupation; hobbies / sports / activities *

Do you have/have you had within the last 6 months any of the listed contraindications below? *

Other - enter contraindications or other relevant information here

I understand that thorough & honest responses are essential to my safety. I confirm that the information stated within this response is accurate to the best of my knowledge and I will inform of any subsequent changes at the session. I understand that some contraindications may require alterations to the planned service, or result in an inability to provide services. I also understand that prior to treatment a physical assessment may be necessary. I am happy to proceed. *

Yes

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CONTRAINDICATIONS

Musculoskeletal Issues

eg Strains/Sprains/Fractures/Myositis/Joint Replacement/Arthritis/Osteoporosis/Bursitis/Tendonitis.

Circulatory Issues

eg Heart Condition/Hypertension/Hypotension/DVT/Phlebitis/Varicose Veins/Haemophilia/CV Disease

Neurological Issues

eg Epilepsy/Sciatica/Neuralgia/MS/Parkinsons

Skin Issues

eg Eczema/Acne/Athletes Foot/Warts/Dermatitis/Psoriasis/Impetigo/Cuts/Bruises/Burns/Undiagnosed Lumps

Respiratory Issues

eg Asthma/Pneumonia/Bronchitis/Sinusitis/Cold/Cough/Flu

Immune Issues

Cancer/Rheumatoid Arthritis/HIV/AIDS

Digestive Issues

eg IBS/Constipation/Diarrhoea/Gall Stones/Kidney Stones/Urinary Tract Infection

Miscellaneous Issues

eg Diabetes/Allergies/Operations/Pregnancy/Glandular Fever/Headaches/Psychological Issues/Substance Abuse/Menstrual Issues/Feeling Unwell

Clinic and mobile

Sports Massage therapy

in Brentwood, Essex

PRE-VISIT QUESTIONNAIRE

CONTRAINDICATIONS

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