Treatment Evidence Form Unit 822 – Provide Body Massage College Name: College Number: Learner Name: Learner Number: Date: PERSONAL DETAILS Age group: Under 20 20–30 Lifestyle: Active Sedentary Last visit to the doctor: Client Name: Address: Profession: Tel. No: Day Eve 30–40 40–50 50–60 60+ 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 Any dysfunction of the nervous system (e.g. Cardio vascular conditions (thrombosis, phlebitis, Multiple Sclerosis, Parkinson’s disease, Motor hypertension, hypotension, heart conditions) Neurone disease) Haemophilia Bells Palsy Any condition already being treated by a GP or Trapped/Pinched nerve (e.g. sciatica) another practitioner Inflamed nerve Medical oedema Cancer Osteoporosis Postural deformities Arthritis Cervical spondylitis Nervous/Psychotic conditions Spastic conditions Epilepsy Kidney infections Recent operations Whiplash Diabetes Slipped disc Asthma Undiagnosed pain Chemotherapy When taking prescribed medication Radiotherapy Acute rheumatism CONTRAINDICATIONS THAT RESTRICT TREATMENT 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 tissue (2 years for major operation and 6 months for a small scar) Sunburn Unit 822 Provide Body Massage Treatment Evidence Form (select if/where appropriate): Hormonal implants Menstruation (abdomen - first few days) Haematoma Hernia Recent fractures (minimum 3 months) Gastric ulcers After a heavy meal Conditions affecting the neck Any metal pins or plates Loss of skin sensation (test with tactile test) IUD (coil) Anaphylaxis Muscle fatigue Pacemaker Body piercing Excessive erythema 1 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 Digestive problems: Constipation Circulation: Heart Kidney problems Bloating Blood pressure Stiff joints Headaches Liver/Gall bladder Fluid retention Stomach Tired legs Varicose veins Cellulite Cold hands and feet Gynaecological: Irregular periods Nervous system: Migraine P.M.T Tension Immune system: Prone to infections Menopause Stress Herbal remedies taken: Yes No Ability to relax: Good Moderate Sleep patterns: Good Poor No Colds Other: Chest Sinuses If yes, type and name of medication Poor No. of hours: Do you see natural daylight in your workplace? Yes Do you work at a computer? Yes Do you eat in a hurry? Yes Coil If yes, type and name of remedy Average Do you eat regular meals? Yes Pill Depression Sore throats Regular antibiotic/medication taken: Yes H.R.T No No If yes, how many hours: No No Do you take any food/vitamin supplements? Yes No If yes, type and name of supplement(s) How many portions of each of these items does your diet contain per day? Fresh fruit: Fresh vegetables: Dairy produce: Protein: Sweet things: Source of protein Added salt: Added sugar: How many units of these drinks do you consume per day? Tea: Coffee: Fruit juice: Water: Soft drinks: Do you suffer from food allergies? Yes No Do you suffer from eating disorders? Bingeing: Yes Under eating: Yes No Overeating: Yes No No Do you smoke? Yes No If yes, how many per day? Do you drink alcohol? Yes Do you exercise? Yes No No What is your skin type? Dry If yes, how many units per day? Occasional Oily Irregular Normal Hay Fever Asthma Regular Young Do you suffer/have you suffered from: Dermatitis Allergies Others: Acne Types of exercise: Mature Eczema Psoriasis Skin cancer Treatment objective: (select if/where appropriate): Stimulating Relaxing Anti cellulite Invigorating Uplifting Use of infrared Soothing Sense of wellbeing Unit 822 Provide Body Massage Treatment Evidence Form 2 BODY ANALYSIS Height: Weight: Skin Type/Condition: Types of Fat: Body type: Postural conditions: Muscle Tone: Treatment details: Client feedback: After/Home care advice given: Client signature................................................................. Learner signature...................……………......................... Unit 822 Provide Body Massage Treatment Evidence Form 3