1st Sport Consultation Form
Fields
Client name:
*
Date of Birth:
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Age:
*
Address:
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Weight (kg):
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Height (m):
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Tel No:
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(
)
-
Doctor name:
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Surgery Address:
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Tel No:
*
(
)
-
Occupation:
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Exercise routine:
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Have you recently visited: doctor/consult/physiotherapist/osteopath/sport therapist other:
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Yes
No
Details:
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Are you currently taking any medications?
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Yes
No
Details:
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Main reason for attending:
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Any current problem or known history of the following:
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Yes
No
Musculo-skeletal problems:
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Arthritis; Osteoporosis; Fractures; Joint replacement; Pins and plates:
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Heart/Circulatory/Arterial/Blood pressure:
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Thrombosis/Embolism/Varicose veins:
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Skin conditions: Cuts/Bruises/Burns/Rashes/Scars/ Warts/Moles:
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Pregnancies:
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Major/Recent illnesses:
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Major/Recent operations:
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Digestive/Urinary/Endocrine/Respiratory/Neurological problems:
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Specific aches, pains, problems and injuries:
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Head/Neck/Thoracic/Lumbar/ Sacral/Coccygeal/Abdominal:
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Shoulder girdle/ Upper arm/Elbow/Lower arm/ Wrist/Hand/Fingers/Pelvic girdle/Hip/Upper leg/Knee:
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Lower leg/Ankle/Foot/Toes:
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General notes: accidents; sports injuries;headaches;migraines;vision;audition;olfaction;
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sinuses;fatigue;depression;sleep;stress;energy;wellbeing;diet;fluid intake;smoking;alcohol
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I confirm that the above information is correct to the best of my knowledge.
Yes
No