Your Practice

Sports Therapy Assessment

Personal Details

Tell us a little about yourself.

First Name

Surname

Address

Phone

Date of Birth You can type your date of birth (dd/mm/yyyy) or choose it from the calendar.

GP name & surgery

Emergency contact name

Emergency contact phone

Relationship to you

Injury Details

Injury location

Date of injury

How did the injury occur?

Pain Assessment

Pain scale (1 = no pain, 10 = worst pain) Please enter a number from 1 to 10

What makes the pain worse?

What relieves the pain?

Previous treatment for this injury

Medical History

Help your therapist provide safe treatment.

Relevant medical history

Current medication

Functional Assessment

How does this injury affect daily activities, work or sport?

Areas you would like the therapist to focus on

Treatment Consent

Data Protection (UK GDPR)

I hereby declare that the details are true and correct to the best of my knowledge and I undertake to inform you of any changes immediately. I have read and acknowledged the Privacy/GDPR policy. Thank you kindly for visiting us today and completing this form. Hope to see you again soon.

Client Signature

Please sign below.

Date

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