ParQ – Flexi Therapy

Every client is required to fill out a parQ before coming for treatment.

Name: *

First

Last

Date of Birth: *

Email: *

Address: *

Phone Number: *

Emergency Contact: *

Do you currently have any injuries? (if so please expand): *

Have you had any form of surgery in the last year? (if so please expand): *

What is your level of physical exercise? (please expand): *

Are you pregnant? *

Have you been diagnosed with any of the following:

Please tick the boxes which apply to you.

Are you currently taking any regular medication? (if so what): *

Tick this box to confirm that you consent to assesment and treatment by Kate Czepulkowski (FlexiTherapy): *

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