Client Consultation Form – Thai Massage
College Name:
Client Name:
College Number:
Address:
Student Name:
Student Number:
Profession:
Date:
Tel. No: Day
Eve
PERSONAL DETAILS
Age group: Under 20
20–30
Lifestyle: Active
Sedentary
Last visit to the doctor:
GP Address:
No. Of children (if applicable):
Date of last period (if applicable):
30–40
40–50
50–60
60+
CONTRAINDICATIONS (select if/where appropriate):
Never treat unless the injury has been diagnosed and treatment has been recommended by a
medical practitioner.
Pregnancy
Asthma
Cardio vascular conditions (thrombosis,
Any dysfunction of the nervous system (e.g.
phlebitis, hypertension, hypotension, heart
Muscular sclerosis, Parkinson’s disease,
conditions)
Motor neurone disease)
Haemophilia
Bells Palsy
Any condition already being treated by a GP
Trapped/Pinched nerve (e.g. sciatica)
or another health professional, e.g.
Inflamed nerve
Physiotherapist, Osteopath, Chiropractor,
Cancer
Coach
Postural deformities
Medical oedema
Spastic conditions
Osteoporosis
Kidney infections
Arthritis
Whiplash
Nervous/Psychotic conditions
Slipped disc
Epilepsy
Undiagnosed pain
Recent operations
When taking prescribed medication
Diabetes
Acute rheumatism
CONTRAINDICATIONS THAT RESTRICT TREATMENT (select if/where appropriate):
Fever
Abrasions
Contagious or infectious diseases
Scar tissues (2 years for major operation and
Under the influence of recreational drugs or
6 months for a small scar)
alcohol
Sunburn
Diarrhoea and vomiting
Hormonal implants
Skin diseases
Abdomen (first few days of menstruation
Undiagnosed lumps and bumps
depending how the client feels)
Localised swelling
Haematoma
Inflammation
Hernia
Varicose veins
Recent fractures (minimum 3 months)
Pregnancy (abdomen)
Cervical spondylitis
Cuts
Gastric ulcers
Bruises
After a heavy meal
WRITTEN PERMISSION REQUIRED BY GP/SPECIALIST (which should be attached to the
consultation form):
Yes
No
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 1
Do you see natural daylight in your workplace? Yes
No
Do you work at a computer? Yes
No
If yes how many hours 1
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: 0 Fresh vegetables: 0 Protein: 0 source?
Dairy produce: 0 Sweet things: 0 Added salt: 0 Added sugar: 0
How many units of these drinks do you consume per day?
Tea: 0 Coffee: 0 Fruit juice: 0 Water: 0 Soft drinks: 0 Others: 0
Do you suffer from food allergies? Yes
No
Bingeing? Yes
No
Overeating? Yes
No
Do you smoke? No
Yes
How many per day? 1-5
Do you drink alcohol? No
Yes
How many units per day? 1
Do you exercise? None
Occasional
Irregular
Regular
Type:
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: 1–10 (10 being the highest)
At work 1 At home 1
CURRENT THERAPY TREATMENT:
Type of therapy:
When this treatment started:
Frequency:
Infrequently
Once a fortnight
Reasons for therapy treatment:
Aims of therapy treatment:
Once a week
Daily
Reasons for Thai Massage:
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.
Student’s/Therapist’s Signature………………………………………….
Client’s Signature……………………………………………………………
THAI MASSAGE FOLLOW UP SHEET
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:
Reflective Practice: