MB Massage therapy, Injurie Assessment form


1. Name and Surname *


2. Contact number *


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:


7. How long have you had this problem for?


8. Have you seen any other med practitioner related to your current injury /condition?


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


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


11. Are you a key worker?


12. Have you been suffering over the last two weeks from Coronavirus symptoms such as:

Check out our survey templates or create your own.