Holistic Massage Client Consultation Form (1)

Download Holistic Massage Client Consultation Form (1)

Post on 14-Dec-2015




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Example of consultation form


Client Consultation Form Holistic MassageCollege Name: College Number: Student Name: Student Number: Date: Client Name: Address: Profession: Tel. No: Day Eve PERSONAL DETAILSAge group: Under 20|_| 2030|_| 3040|_| 4050|_| 5060|_| 60+|_|Lifestyle: Active|_| Sedentary|_|Last visit to the doctor: GP Address: No. of children (if applicable): Date of last period (if applicable): CONTRAINDICATIONS REQUIRING MEDICAL PERMISSION in circumstances where medical permission cannot be obtained clients must give their informed consent in writing prior to treatment. (select if/where appropriate):Pregnancy |_|Cardio vascular conditions (thrombosis, phlebitis, hypertension, hypotension, heart conditions) |_| Haemophilia |_| Any condition already being treated by a GP or another complementary practitioner Medical oedema |_|Osteoporosis |_| Arthritis |_|Nervous/Psychotic conditions |_| Epilepsy |_| Recent operations |_|Diabetes |_|Asthma |_| Any dysfunction of the nervous system (e.g. Muscular sclerosis, Parkinsons disease, Motor neurone disease) |_| Bells Palsy |_|Trapped/Pinched nerve (e.g. sciatica) Inflamed nerve |_| Cancer |_| Postural deformities |_|Spastic conditions |_| Kidney infections |_| Whiplash |_|Slipped disc |_| Undiagnosed pain |_| When taking prescribed medication |_|Acute rheumatism|_|CONTRAINDICTIONS THAT RESTRICT TREATMENT (select if/where appropriate):Fever |_|Contagious or infectious diseases |_|Under the influence of recreational drugs or alcohol |_| Diarrhoea and vomiting |_|Skin diseases |_| Undiagnosed lumps and bumps |_|Localised swelling |_| Inflammation |_| Varicose veins |_|Pregnancy (abdomen) |_|Cuts |_| Bruises |_| Abrasions |_| Scar tissues (2 years for major operation and 6 months for a small scar) |_|Sunburn |_| Hormonal implants |_| Abdomen (first few days of menstruation depending how the client feels) |_|Haematoma |_|Hernia |_|Recent fractures (minimum 3 months) |_| Cervical spondylitis |_| Gastric ulcers |_| After a heavy meal |_|Conditions affecting the neck |_|WRITTEN PERMISSION REQUIRED BY:GP/Specialist |_|Informed consent |_|Either of which should be attached to the consultation form.PERSONAL INFORMATION (select if/where appropriate): Muscular/Skeletal problems: Back|_| Aches/Pain|_| Stiff joints|_| Headaches|_|Digestive problems: Constipation|_| Bloating|_| Liver/Gall bladder|_| Stomach|_| Circulation: Heart|_| Blood pressure|_| Fluid retention|_| Tired legs|_| Varicose veins|_| Cellulite|_| Kidney problems|_| Cold hands and feet|_| Gynaecological: Irregular periods|_| P.M.T|_| Menopause|_| H.R.T|_| Pill|_| Coil|_| Other Nervous system: Migraine|_| Tension|_| Stress|_| Depression|_|Immune system: Prone to infections|_| Sore throats|_| Colds|_| Chest|_| Sinuses|_|Regular antibiotic/medication taken? Yes |_| No |_| If yes, which ones Herbal remedies taken? Yes|_| No|_| If yes, which ones Ability to relax: Good|_| Moderate|_| Poor|_| Sleep patterns: Good|_| Poor|_| Average No. of hours Do you see natural daylight in your workplace? Yes |_| No|_|Do you work at a computer? Yes|_| No|_| If yes how many hours Do you eat regular meals? Yes|_| No|_|Do you eat in a hurry? Yes|_| No|_|Do you take any food/vitamin supplements? Yes|_| No|_| If yes, which ones How many portions of each of these items does your diet contain per day? Fresh fruit: Fresh vegetables: Protein: source? Dairy produce: Sweet things: Added salt: Added sugar: How many units of these drinks do you consume per day? Tea: Coffee: Fruit juice: Water: Soft drinks: Others: Do you suffer from food allergies? Yes|_| No|_| Bingeing? Yes|_| No|_| Overeating? Yes|_| No|_|Do you smoke? No |_| Yes |_| How many per day? Do you drink alcohol? No|_| Yes|_| How many units per day? Do you exercise? None|_| Occasional|_| Irregular|_| Regular|_| Types What is your skin type? Dry|_| Oil |_| Combination|_| Sensitive|_| Dehydrated|_| Do you suffer/have you suffered from: Dermatitis|_| Acne|_| Eczema|_| Psoriasis|_| Allergies|_| Hay Fever|_| Asthma|_| Skin cancer|_|Stress level: 110 (10 being the highest) At work At home Reason for treatment:Details of how the Therapist conducted the treatment: Details of how the client felt during and after the treatment:Details of home care advice given:Overall conclusion of the case study including reflective practice:A CLIENT PROFILE MUST BE INCLUDED IN THE CASE STUDY. Clients Signature.Students/Therapists Signature...................................................HOLISTIC MASSAGE FOLLOW UP SHEETDetails of how the Therapist conducted the treatment:Details of how the client felt during and after the treatment:Details of home care advice given:Overall conclusion of the case study including reflective practice:Date of treatment:


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