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TREATMENTS
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Kinefit Form
First name
*
Last name
*
Email
*
Birthday
Day
Month
Year
Phone
What is your main reason for booking today?
*
When did this issue start?
Less than 1 week ago
1-4 weeks ago
1-3 months ago
Over 3 months ago
Have you had any treatment for this before?
Physiotherapy
GP Consultation
Massage
Other
Are you currently under the care of a GP or specialist?
Yes
No
Do you have (or have you ever had) any of the following?
Heart condition / high blood pressure
Diabetes
Asthma / breathing issues
Circulatory problems
Arthritis
Recent fracture / joint injury
Recent surgery (<6 months)
Skin conditions
Cancer (past or present)
Nerve or sensory disorders
Possibility that you are pregnant
None of the above
Are you currently taking any medication?
Yes
No
Do you have any allergies (e.g. oils, nuts etc.)?
*
How active are you?
Sedentary
Lightly active
Moderately active
Very active
What type of activity or training do you do (if any)?
How often do you train per week?
1-2
3-4
5+
Preferred massage pressure level
Light
Moderate
Deep
Areas to focus on
Neck & shoulders
Upper back
Lower back
Legs
Arms
Full body
Other
Would you like your session to include the following treatments?
Cupping
Dry needling
Gua sha
Assisted stretching
Any areas to avoid or sensitive areas?
Please confirm you agree to the following:
I confirm the information is accurate to the best of my knowledge.
I understand that sports massage is not a substitute for medical care.
I consent to treatment and understand I can withdraw consent at any time.
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