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Client Information:

Emergency Contact Information:

Lifestyle Information:

Medical History (select which apply):

Reason for Visit: Questions around the affected area, how it occurred etc.

Data Protection & Consent to Treatment:

All data will be handled in accordance with the Data Protection Act, 1988. Medical records will be stored under lock and key, and only accessed by authorized personnel. Disclosure of information may be made to appropriate health professionals. Such as any referral required or GP.

All assessments and treatments will be performed by a qualified, registered and insured therapist, who will practice within the defined scope of practice as per the relevant governing bodies in the United Kingdom (UK). You must advise your therapist of any factor that may affect your treatment or diagnosis.

Following examination and assessment, an explanation of the therapist’s opinion and proposed treatment will be provided. It is therefore important that you fully understand the diagnosis, recommendations, procedures and treatment techniques that may be involved, as well as any likely side effects of the treatment.

Your therapist should make for every effort to ensure you understand the procedures involved, however if you are in doubt please do not hesitate to ask for further information. With certain injuries/conditions a degree of undress may be required and this will be explained at the time by your therapist. To carry out the assessment your therapist may need to place their hands upon you in order to assess your injury, this certifies the consent for treatment You are entitled to be accompanied during any point of the service provided by Origym. SMT Assessments or treatments can be stopped by the patient at any time during the service, if the patient feels the need to.

Objective Assessment:

Assessment Diagnosis:

I hereby give consent for my Sports Massage Therapist to continue with a treatment targeting the diagnosis I have been provided.

Plan: Treatment plan, treatments conducted (techniques), areas targeted (muscles) & re-assessment of Functional test (improvement / regression)

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