Name * First Name Last Name Identify as * Female Male Other Email * Contact phone number * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth * MM DD YYYY Occupation * What sports and/or activities do you do? * Health Fund? * Health fund Extras cover? * Yes No I don't have private health cover Emergency Contact name * Emergency contact phone number * Do you have any limitations for treatment? * Yes No Details of limitations if previous answer is yes What are your expectations for treatment? * Is there a possibility that you are pregnant * Yes No I am Male Do you have varicose veins? * Yes No Do you have sunburn? * Yes No Have you had any recent surgery or do you have scar tissue? * Yes No Details if answer to previous question is yes. Do you have any inflamed or painful areas? * Yes No Details if answer to previous question is yes. High or Low Blood Pressure * High Low Normal Do you have a circulatory disorder? * Yes No Do you take supplements? * Yes No Details if answer to previous question is yes. Do you have arthritis? * Yes No Details if answer to previous question is yes. Do you have any allergies? * Yes No Details if previous answer is yes. Do you have diabetes? * Yes No Have you ever had blood clots or been diagnosed with DVT? * Yes No Have you had any fractures or dislocations * Yes No Details if previous answer is yes. Do you suffer from headaches or migraines? * Yes No Do you have cancer? * Yes No Details if previous answer is yes. Do you have any infectious conditions? * Yes No Are you taking any medications? * Yes No Details if previous answer is yes. Thank you!
