Client Consultation Form – Body Treatments
College Name:
College Number:
Student Name:
Student Number:
Date:
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):
Client Name:
Address:
Profession:
Tel. No: Day
Eve
30–40
40–50
50–60
60+
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,
Muscular sclerosis, Parkinson’s disease, Motor
hypertension, hypotension, heart conditions)
neurone disease) Bells Palsy
Haemophilia
Trapped/Pinched nerve (e.g. sciatica)
Any condition already being treated by a GP or
Inflamed nerve
another practitioner
Cancer
Medical oedema
Postural deformities
Osteoporosis
Spastic conditions
Arthritis
Kidney infections
Nervous/Psychotic conditions
Whiplash
Epilepsy
Slipped disc
Recent operations
Undiagnosed pain
Diabetes
When taking prescribed medication
Asthma
Acute rheumatism
CONTRAINDICTIONS THAT RESTRICT TREATMENT (select if/where appropriate):
Fever
Abdomen (first few days of menstruation
Contagious or infectious diseases
depending how the client feels)
Under the influence of recreational drugs or
Haematoma
alcohol
Hernia
Diarrhoea and vomiting
Recent fractures (minimum 3 months)
Skin diseases
Cervical spondylitis
Undiagnosed lumps and bumps
Gastric ulcers
Localised swelling
After a heavy meal
Inflammation
Conditions affecting the neck
Varicose veins
Any metal pins or plates
Pregnancy (abdomen)
Loss of skin sensation (test with tactile test)
Cuts
IUD (coil)
Bruises
Anaphylaxis
Abrasions
Muscle fatigue
Scar tissues (2 years for major operation and 6
Pacemaker
months for a small scar)
Body piercing
Sunburn
Excessive erythema
Hormonal implants
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
Cold hands and feet
Gynaecological: Irregular periods
Nervous system: Migraine
P.M.T
Tension
Menopause
Stress
Immune system: Prone to infections
H.R.T
Pill
Coil
Depression
Sore throats
Colds
Chest
Sinuses
Regular antibiotic/medication taken:
Herbal remedies taken:
Ability to relax: Good
Moderate
Sleep patterns: Good
Poor
Poor
Average No. of hours:
Do you see natural daylight in your workplace? Yes
Do you work at a computer? Yes
Do you eat regular meals? Yes
Do you eat in a hurry? Yes
No
No
If yes how many hours:
No
No
Do you take any food/vitamin supplements? Yes
No
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
Overeating? Yes
No
Yes
Do you exercise? None
Yes
How many units per day? 1
Occasional
What is your skin type? Dry
Oil
Irregular
Combination
Do you suffer/have you suffered from: Dermatitis
Hay Fever
Asthma
Skin cancer
Stress level: 1–10 (10 being the highest)
1
No
How many per day? 1-5
Do you drink alcohol? No
At work
Bingeing? Yes
No
Do you smoke? No
Allergies
Cellulite
At home
1
Regular
Types
Sensitive
Acne
Dehydrated
Eczema
Psoriasis
Other:
FIGURE DIAGNOSIS
Height:
Weight:
Body type:
Areas of soft fat:
Areas of cellulite:
Postural conditions:
MEASUREMENTS:
Upper chest (under the arms):
Maximum chest:
Below bust:
Waist:
Hips:
Maximum buttocks (on hairline):
Top of thigh: Right:
Left:
1inch/2cm above knee: R:
L:
Maximum calf muscle: R:
L:
Ankle: R:
L:
Middle of upper arm: R:
L:
Middle of lower arm: R:
L:
Wrist: R:
L:
MUSCLE TEST (select if/where appropriate):
Quadriceps: Excellent
Good
Average
Hamstrings: Excellent
Good
Average
Biceps:
Excellent
Good
Average
Triceps:
Excellent
Good
Average
Abdominal: Excellent
Good
Average
EXERCISE ADVICE:
TESTS
Nerve sensitivity test: Yes
Heat sensitivity test: Yes
No
No
Poor
Poor
Poor
Poor
Poor
Treatment details:
Client Feedback:
After/Home care advice given:
Student’s/Therapist’s signature.........................................
Client’s signature.................................................................
BODY TREATMENTS FOLLOW UP SHEET
Treatment Details:
Client Feedback:
After/Home care advice given:
Date of treatment.........................................