Email Address *Name *Date of Birth *OccupationDetails of any hearing loss/sight loss/or disability:If you are pregnant, is your pregnancy stable and what stage are you at? Leave blank only if you are not pregnantCheck the relevant boxes if you have any of the following conditions:DiabetesCardiac disorders, including a history or risk of embolismOsteoporosisUnstable Blood Pressure (high or low)Cancer, tumours or swellings (including those of unknown cause)Local Circulatory InsufficiencyDeep vein thrombosis or recent history or risk ofAn illnesses in the acute stage where inflammation may be present e.g. acute flare up of rheumatoid arthritis or osteoarthritis?OtherDescribe your condition: location, pain or tightness etc. *Do you have limited range of motion at the site of the condition? *What aggravates it? Is it during a particular activity or during a particular time of day/night? *Is the area painful to touch or are there signs of inflammation? *Describe if you have any loss of sensation at the area in question. Only leave this blank if you are not experiencing any loss of sensationDescribe if you have pain or discomfort that radiates elsewhere. Only leave this blank if you are not experiencing any radiating pain/discomfortIf you experience discomfort or pain please rate the intensity at rest *012345678910If you experience discomfort or pain please rate the intensity at during aggravating activity *012345678910What eases it? Ice/heat/rest/a certain activity? *Upload a picture (more than one if needed) or a video of the site of your condition and/or any restrictions you may be experiencing (e.g. limits in range of motion, walking/running gait).Drag and Drop (or) Choose FilesWhat are your goals and/or what do you want to achieve with Injury Freedom?I confirm that I have answered all questions truthfully to the best of my knowledge. If this is not the case and you need help please do not submit this form and contact us via the website (www.injuryfreedom.co.uk) *I confirm that I have answered all questions truthfully to the best of my knowledgeClick here to indicate that you have read and agree to the terms presented in the Terms and Conditions Agreement and Privacy Policy (found at www.injuryfreedom.co.uk) *I have read and agree to the terms presented in the Terms and Conditions Agreement and Privacy Policy (found at www.injuryfreedom.co.uk)CurrencyGBPCredit / Debit Card *Consent *Yes, I agree with the privacy policy and terms and conditions.Submit
