Date of Birth:
Date of Birth:
Do you require a home visit? *
Travel costs are applicable
Contact preference to book the first session *
If you prefer me to call you to book in please let me know the best times to reach you - saves us playing telephone tennis!
Payment Method: *
Payment in full is required before the first session.
How many sessions do you want to book? *
For cash payments only - if you've bought via the website you've already chosen before paying (tick Not Applicable).
Do you need a receipt? *
For cash payments or bank transfers only. You'll be sent a Sales Receipt. If you’ve bought via the website your order confirmation email constitutes your receipt.
Describe the reason for your visit (e.g if it's for a specific injury, chronic pain etc).
Note your expectations and goals if you having, e.g to climb the stairs without being in pain or the ability to drive pain-free
Do you have or have you ever had: *
Are you currently taking any medication? *
Please describe any in the past or in recent history.
Note down any conventional or alternative treatments you've had.
How do you rate your pain today?
Please refer to the Universal Pain Assessment Tool
Go through the body joint-by-joint. Even if you think a previous injury, illness or infection isn’t relevant to your current complaint, please include. More is better!
Whether you were delivered naturally, via C-Section, forceps etc. If you don't know, please leave blank.
Whether it was unassisted, a C-Section, forceps, induced etc
I am prone to over-training when I exercise:
Do you walk your dog on the same side most days?
Do you carry a bag mainly on one shoulder?
Do you sleep on the same side of the bed most nights?
Day-to-day I have a lot of energy:
Day-to-day I feel stressed:
My work shoes are uncomfortable:
My job is stressful:
I have a sedentary lifestyle:
How did you hear of Movementum?
Medical/Liability Waiver *
I am fully aware that the services I wish to receive are those of a holistic nature and do not serve as a substitute for professional medical advice, examination, diagnosis or treatment. I understand the information I have been given to be the truth and consent to the treatment of Anatomy in Motion and will inform Frances of any changes to my medical status if they have changed since completing this online form. I understand that if I have been untruthful with my details or have failed to give enough relevant information any treatment could be adversely affected. Frances does not claim to cure or to diagnose any medical condition in the same regard as a physician, as her opinion is that of a holistic, complementary and alternative therapist and her professional opinions, advice, examinations and recommendations do not constitute the medical advice of a doctor/physician.
Session Booking *
If a date cannot be agreed at the end of an in-person session it is up to you, the client, to ensure you book all of your sessions. Movementum will not be held responsible for ensuring all packages and sessions are used and are unable to remind you to book appointments outside of session hours.
Late Arrival Policy *
We request that you arrive 10 minutes prior to your first session to allow time to fill out any required paperwork and 5 minutes prior to all other sessions. We understand that issues can arise that may cause you to be late for your sessions. However, we ask that you contact us if this ever occurs so we can do our best to accommodate you. As we run on a tight schedule, clients who arrive late to their appointment may receive a shorter treatment in the effort not to inconvenience other booked clients.
Cancellation Policy and Missed Appointments *
We want to make our policy as clear as possible as it can be upsetting when people miss or need to change an appointment, often because of genuine and stressful reasons. It is our policy that clients are responsible for all appointments that they have scheduled. Clients who choose not to attend, or those who call to cancel their appointments at the last minute are still responsible for these appointment times. Therefore the following policy will apply: We require a minimum of 24 hours’ notice for cancellation of a session via email, phone call or text message. For missed appointments, or any appointment changed, altered, moved or cancelled for any reason with less than 24 hours’ notice you will incur the full appointment fee. Short notice cancellations (less than 24 hours) will be counted as one of your sessions. I understand that emergencies can arise and illnesses do occur at inopportune times. If you have a fever, a known infection, or have experienced vomiting or diarrhoea within 24 hours prior to your appointment time, I request that you cancel your session. I will do my best to give advanced notice if I need to cancel due to bad weather and ask you do the same. Please do not risk your own safety trying to make your appointment.
Privacy Policy *
We do not share any of your information with any third parties or profit from your personal information and data. Our privacy policy can be found at the bottom of each page.
Declaration of consent: *
I have completed this form to the best of my ability and knowledge and agree to inform Frances if any of the above information changes at any time.
Please write your name or initials in the box below. By signing this form electronically you are agreeing to the terms and conditions herein.
Date Today: *
Date Today:
Pain and Injury Sessions.png

Pain & injury form

Thank you for doing the following:

• Complete the form at least TWO DAYS in advance of the date of your session to allow time to prepare.

• Use the Universal Pain Assessment tool to measure your current pain level.

• Arrive a little bit early before the sessions to allow us to have a chat, check-in and catch up. If you arrive late, I’m unable to finish late.