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OJJ SPORTS THERAPY

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Patient PAR-Q & Medical History Form
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Personal Details

First name*

Last name*

Birthday*

Day

Month

Year

Phone*

Email*

Occupation*

Reason for your visit

What are you seeking treatment for?*

When did the issue start?*

Describe how the issue started*

Medical History

Do you suffer any chest pain during activity?*

Yes

No

Do you suffer from dizziness or faintng?*

Yes

No

Does joint/muscle pain worsen during activity?*

Yes

No

If you have answered yes to any of the above questions, please provide more detail below.

Do you suffer, or have you suffered from any of the below. Tick all that apply*

Asthma

Diabetes

Epilepsy

High blood pressure

Heart condition

Stroke

Arthritis

Osteoporosis

Cancer

Respiratory issues

Neurological issues

Pregnant/recently pregnant

Other

Please provide details of all that have been ticked

Prior injuries & surgeries

Please provide full details

Medication & Allergies

Please provide full details

Lifestyle & Activity

What sports and/or activities do you regularly participate in.

How often to you train/work out/exercise per week?

Do you smoke/vape?*

Yes

No

Consent

I confirm that the information provided is accurate and that I consent to assessment and treatment

Signature

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OJJ SPORTS THERAPY

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