Home
About Andrew
Personal Training
Manual Therapy
Personal Training / Group Training Options
Pre Training Questionnairre
Manual Therapy Questionnairre
Contact
Home
About Andrew
Personal Training
Manual Therapy
Personal Training / Group Training Options
Pre Training Questionnairre
Manual Therapy Questionnairre
Contact
Manual Therapy QUESTIONNAIRE
Name
*
First Name
Last Name
Email
*
Mobile Number
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Date of Birth
*
MM
DD
YYYY
Occupation
*
How did you hear about me?
*
Gender
*
Male
Female
Prefer not to say
Medical conditions? i.e diabetes, heart disease, cancer?
*
Yes/No - if yes, describe
Collagen, restyle, botox injections?
*
Yes/No - if yes describe
Implants anywhere in the body?
*
Yes/No - if yes describe
Are you taking any medication
Yes/No - if yes describe
Contagious skin disease
*
Yes/No - if yes describe
Have you recently had surgery?
*
Yes/No - if yes describe
Metal pins/ Plates/ heart pacemaker or other?
*
Yes/No - if yes describe
Do you have HIV/Aids/autoimmune disease?
*
Yes/No - if yes describe
Are you currently undergoing treatment fro any illness/ injury ?
*
Yes/No - if yes describe
Do you have any allergies?
*
Yes/No - if yes describe
Have you recently used any form of skin peels?
*
Yes/No - if yes describe
Should I be aware of any other Medical conditions
*
Are you Pregnant?
*
Yes
No
N/A
I can confirm, to the best of my knowledge, that the answers given are correct and that I have not withheld any information that may be relevant to my treatment.
*
Please Tick
I agree to notify Andrew Mayers about any changes to my medical history everytime I have further treatment
*
Please Tick
Today's date
*
Select a date
MM
DD
YYYY
Thank you!
