Consultation Form printable pdf download

Consultation Form

Mark Diment

MSF MAB Sports Therapist & ITEC DIP

Consultation Form

Surname: ____________________________ Mr/Mrs/Miss/Ms

First Name: __________________________

Address: ______________________________________________________________

Postcode: ____________________________ Occupation: _____________________

Tel No: __________________________Email________________________________

Date Of Birth: _________________________

Doctors Details: ______________________________________ Tel:______________

Do you have or had any of the following:

Rheumatoid arthritis

Any allergies

Fibrosis / muscle discomfort

Whiplash

Cancer or malignant disease

Diabetes

Disc herniated or prolapsed

Headaches / migraines

High / low blood pressure

Broken bones / fractures

Osteoarthritis

Osteoporosis

Spondylitis

Epilepsy

Heart problems

Sciatica

Are you:

Pregnant

YES/NO

Recovering from a recent operation or treatment

YES/NO

Presently taking any medication prescribed by your doctor

YES/NO

Aware of any condition you have which is not mentioned on this form YES/NO

Patients declaration

I declare that to the best of my knowledge the information I have given is correct. The

treatment procedure has been fully explained to me. I am aware that I will be receiving

sports therapy treatment incorporating manipulation. I understand that more than one

treatment may be necessary and that certain aspects of the treatment may be uncomfortable. I

also understand following treatment there may be some discomfort or aching experienced for

a few days. All of my questions have been answered and therefore willing to proceed.

Patients signature _____________________________ Date _________

Consultation Form