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MB Massage therapy, Injurie Assessment form
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1.
Question 1.
Name and Surname
Required
- Required.
*
2.
Question 2.
Contact number
Required
- Required.
*
3.
Question 3.
Email address
Required
- Required.
4.
Question 4.
Please describe your issue/injurie/pain
5.
Question 5.
Please indicate level of pain (From 0- no pain to 10-unbearable pain)
6.
Question 6.
Is this problem interfering with your:
Work
Sleep
Daily activities
7.
Question 7.
How long have you had this problem for?
8.
Question 8.
Have you seen any other med practitioner related to your current injury /condition?
GP Doctor
Hospital consultant
Physio therapist
Other medical practitioner
NOONE OF THEM
9.
Question 9.
Did you receive any verbal consent from a medical practitioner to seek help from Sports/massage therapist?
Yes
No
10.
Question 10.
Would you consider yourself as an emergency patient ,who requires an emergency treatment (appointment)?
Yes
No
11.
Question 11.
Are you a key worker?
Yes
No
12.
Question 12.
Have you been suffering over the last two weeks from Coronavirus symptoms such as:
New continuous caught
High fever or chills
Loss or change to your sense of smell or taste
Shortness of breath
NONE OF THE ABOVE