Consultation

Name*
Date Of Birth*
Mobile Number*
Email*
Postcode
Next of kin / emergency contact name and phone number*
Are You Pregnant?*
- No
- Yes
Number of weeks into pregnancy?
Which hand do you prefer to use?
- Left
- Right
In the past 6 months have you visited any of the following? GP / Consult / Physio / Osteo / Chiro / Sports Ther / Pod. If yes please provide details:
Please tick any and all of the following which currently apply to you.
- Muscular-skeletal problems e.g. Strains / sprains / fractures / myosotis / joint replacement / arthritis / osteoporosis / bursitis / tendonitis / other
- Circulatory problems e.g. Heart condition / hypertension / hypotension / DVT / phlebitis / varicose veins / haemophilia / cv disease / other
- Neurological problems e.g. Epilepsy / sciatica / neuralgia / MS / Parkinson's / other
- Skin problems e.g. Eczema / acne / athletes foot / warts / dermatitis / psoriasis / impetigo / cuts / bruises / burns / undiagnosed lumps / other
- Respiratory problems e.g. Asthma / pneumonia / bronchitis / sinusitis / cold / cough / flu / other
- Immune problems e.g. Cancer / rheumatoid arthritis / hiv / aids / other
- Digestive problems e.g. IBS / constipation / diarrhoea / gall stones / kidney stones / urinary tract infection / other
- Miscellaneous problems e.g. Diabetes / allergies / recent operations / major operations / unstable pregnancy / glandular fever / headaches / psychological problems / menstrual problems / substance abuse / feeling unwell/ other
Please give details for any highlighted fields including allergies, current medication and / or treatment.*
GP name and address*
When was your last similar treatment?
- Never had one
- More than a year ago
- Between 6 months and a year ago
- Between 1 and 6 months ago
- Less than a month ago
What are the reasons for your visit?
- I have a physical issue which I would like addressed
- I have a non-physical issue which I would like addressed
- I value the relaxation aspect of my treatment
- It is my first treatment and I am curious of the experience
- I have benefited from similar treatments in the past
- It has been recommended to me
- Someone I know has benefited from a similar treatment
How did you hear about Blue Frog therapies?
Is your appointment for a sports massage?*
- Yes
- No
Occupation
Exercise routine including frequency
Sports / hobbies / interests
Diet
- Healthy
- Unhealthy
- Varied
I understand that prior to any treatment a physical assessment needs to be carried out. (This assessment includes observing posture and joint / muscle movement so it is recommended you arrive wearing or with suitable clothing such as fitted sports top and shorts / your workout clothing). I am happy to proceed. PLEASE SIGN BELOW*
I have provided all my known medical information. I acknowledge that massage is not a substitute for medical diagnosis and treatment. I give my consent to receive treatment. PLEASE SIGN BELOW*
Your information is collected only to provide you with a better, safer and more effective session and will not be shared with anyone.*
- I would like to receive your quarterly newsletter
- I prefer not to receive the newsletter

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