MB Massage therapy, Injurie Assessment form

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1. Name and Surname *

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2. Contact number *

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3. Email address *

4. Please describe your issue/injurie/pain

5. Please indicate level of pain (From 0- no pain to 10-unbearable pain)

6. Is this problem interfering with your:

Work
Sleep
Daily activities

7. How long have you had this problem for?

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. Did you receive any verbal consent from a medical practitioner to seek help from Sports/massage therapist?

Yes
No

10. Would you consider yourself as an emergency patient ,who requires an emergency treatment (appointment)?

Yes
No

11. Are you a key worker?

Yes
No

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

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