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.