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Sports Recovery Health Check Form

Please read the following and fill in all that apply.

First name

Last name

Phone

Email

Date of Birth

Day

Month

Year

Address

Sex

Male

Female

Other

Current Activity Levels

Active

Moderate

Sedentary

Contraindications (tick any that apply)

Pregnancy

Haemophilia

Cardiovascular conditions (thrombosis, phlebitis, hypertension, hypotension, heart conditions)

Osteoporosis

Epilepsy

Diabetes

Nervous conditions

Recent operations

Asthma

Trapped nerve

Dysfunctions of the nervous system

Whiplash

Undiagnosed pain

Nerve inflammation

Other

Musculoskeletal problems

Headaches

Aches/pains

Stiff joints

Other

Circulation issues

Heart

Blood pressure

Fluid retention

Varicose veins

Reynauds

Other

List any medication taken

Average hours sleep per night

Average hours per day do you work at a computer?

Do you smoke? If so, how many daily?

Do you drink? If so, how many units per week?

How many times do you exercise per week?

Left or right handed?

Left

Right

List any injuries sustained in the last year

Disclaimer

Please read the following and tick the appropriate boxes.

Client information*

I confirm that I have understood the treatment that I am going to receive.

I confirm that I am willing to proceed with or without confirmation from my GP or consultant

Client Full Name*

Book Here

Address

Fortitude fitness, 5 Brunel Road

Ipswich, Suffolk,

IP2 0HB.

Kelsey Kerridge Sports Centre,

Queen Anne Terrace, Cambridge,

CB1 1NA

Opening Hours

Contact

kirsty.simms258@gmail.com

Monday -Saturday

08:00 - 21:00

@ks.sports_massage

Sunday

09:00 - 18:00

+44 7467453037

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