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AIS Sports Therapy Consultation Form
Hello. Welcome to AIS Sports Therapy
. This consultation form information is used in order to help plan and deliver a safe and effective massage treatment. Please answer the questions to the best of your knowledge.
Your information will not be shared with any third-party and will be strictly confidential.
Thank you.
* Indicates required question
First and Last Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Address (Apartment/Villa number- Building / Street- Area (e.g JRB, Marina, JVC, Business Bay, other...)
*
Your answer
Email
*
Your answer
Phone Number
*
Your answer
Select Treatment:
*
60 Minute Sports Massage
90 Minute Sports Massage
Select Additional Treatment
(If applicable)
:
Cupping
Lifestyle Assessment
Occupation:
Your answer
Would you class your lifestyle as?
Sedentary
Active
Very Active
Clear selection
Water Intake (Glasses per day)
0-2
Option 2
6-8
8+
Clear selection
Do you smoke? (If yes how many per day?)
Your answer
Diet (5 Very Healthy- 1 Low Health)
1
2
3
4
5
Clear selection
Stress Levels (5 High Stress - 1 Low Stress)
1
2
3
4
5
Clear selection
Exercise (Hours per week)
0
1-2
3-4
5-6
7+
Clear selection
Preferred Type of Sports/Exercise
Your answer
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