Home
Booking
Treatments
What do we Offer?
Sports Medicine
Sports Science
Physiotherapy
Health, lifestyle & nutrition
Career
Blog
Contact
About
FAQ
Meet The Team
Success Stories
Home
Booking
Treatments
What do we Offer?
Sports Medicine
Sports Science
Physiotherapy
Health, lifestyle & nutrition
Career
Blog
Contact
About
FAQ
Meet The Team
Success Stories
Questionniare
Telephone Consultations Form
Perceived Stress Questionnaire
Initial Subjective Assessment
Medical Questionnaire and Subjective Assessment Forms
Medical Questionnaire
Patient Social Questionnaire
Event Medical
Name
*
First Name
Last Name
Date of Birth (DD/MM/YY)
*
Mobile Phone Number
Email
*
Your Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
GP Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Medical History
Please Check any of the following conditions that you currently have or have had in the past
Angina
Heart Attack
Heart Disease
Hypertension
Vascular Disease
HIV/AIDS
Asthma
Pneumonia
Shortness of Breath
Tuberculosis
Anemia
Deep Vein Thrombosis
Diabetes
Hepatitis/Jaundice
Polio
Thyroid Insufficiency
Vertigo/Balance Disorders
Migraines
Headaches
Kidney Disease
Stomach Ulcers
Cancer
Tumour
Recent Unexplained Weight Loss
Ankylosing Spondylitis
Broken/Fractured Bone(s)
Spinal Conditionals
Osteoarthritis
Osteoporosis
Gout
Rheumatoid Arthritis
Hearing/Visual Impairment
Epilepsy/Seizures
Parkinson's Disease
Stroke
Bladder/Bowel problems
Past/Pending Surgeries
Anxiety
Depression
Sleeping Disorders
Allergies
Pacemaker
Bleeding Disorders
Pregnant
Other
Additional Information
If you checked any of the above please give details of when it was diagnosed and if it still affects you today. e.g Fractured Left Wrist June 2000, has stiffness
Current Medication
What Medication are you currently taking including Strength, Dosage and Frequency
Terms and Conditions
*
I accept all of the Sheffield Sports Medicine Terms and Conditions including the 48-hour cancellation policy.
Declaration
*
I confirm that I have filled this form to the best of my knowledge and if there is anything that I have not disclosed, Sheffield Sports Medicine and their staff are not liable for any adverse affects from the assessment or treatment.
Date Submitted
*