MQ – SWS Sport and Massage Therapy

SWS Sport and Massage Therapy

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Patients Name *

First

Last

Address *

Date of Birth

Telephone

Doctors Name

Doctors Address

Injury *

When did the injury occur?

How did the injury occur?

Is this a reoccuring injury?

If you answered yes to the above question, have you had any previous treatment on this injury?

Pain Level - 0 is no pain and 10 is unbearable pain

Selected Value: 0

Any muscle lesions / knots present

Any bruising evident?

Joint Restriction?

Inflammation?

Swelling?

Have you sought medical advice and what was the diagnosis?

Height / Weight

Have you experienced or are experiencing any of the conditions below

Are you currently under medical supervison?

If you suffer from any of the above symptoms, please describe in more detail

Any other problems

Please describe any medication you are currently taking

Any other information you feel may be relevant