1st Sport Consultation Form

Fields

Client name: *
Date of Birth: *
Age: *
Address: *
Weight (kg): *
Height (m): *
Tel No: *
() -
Doctor name: *
Surgery Address: *
Tel No: *
() -
Occupation: *
Exercise routine: *
Have you recently visited: doctor/consult/physiotherapist/osteopath/sport therapist other: *
Details: *
Are you currently taking any medications? *
Details: *
Main reason for attending: *
Any current problem or known history of the following: *
Musculo-skeletal problems: *
Arthritis; Osteoporosis; Fractures; Joint replacement; Pins and plates: *
Heart/Circulatory/Arterial/Blood pressure: *
Thrombosis/Embolism/Varicose veins: *
Skin conditions: Cuts/Bruises/Burns/Rashes/Scars/ Warts/Moles: *
Pregnancies: *
Major/Recent illnesses: *
Major/Recent operations: *
Digestive/Urinary/Endocrine/Respiratory/Neurological problems: *
Specific aches, pains, problems and injuries: *
Head/Neck/Thoracic/Lumbar/ Sacral/Coccygeal/Abdominal: *
Shoulder girdle/ Upper arm/Elbow/Lower arm/ Wrist/Hand/Fingers/Pelvic girdle/Hip/Upper leg/Knee: *
Lower leg/Ankle/Foot/Toes: *
General notes: accidents; sports injuries;headaches;migraines;vision;audition;olfaction; *
sinuses;fatigue;depression;sleep;stress;energy;wellbeing;diet;fluid intake;smoking;alcohol *
I confirm that the above information is correct to the best of my knowledge.