Level 3 Award in Taping and Strapping for
Sport and Active Leisure
Unit 426
Case Study Consultation Form (426CSCF)
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 written medical
permission cannot be obtained, clients must sign an informed consent form stating that the treatment
and its effects have been explained to them and confirm that they are willing to proceed without
permission from their GP or Specialist
Heart conditions or any history of heart disease
High blood pressure
Neurological disorders
Any undiagnosed illness
Thrombosis
Diabetics
Risk of haemorrhage
If under the influence of pain-killing drugs
Any condition already being treated by a GP or another healthcare practitioner
CONTRAINDICATIONS THAT RESTRICT TREATMENT (select if / where appropriate)
Acute fever
Inflammatory joint conditions
Musculo-skeletal problems
Acute trauma
After a heavy meal or under the influence of alcohol
If there has been any past difficulty with exercise
Tumour
Open wounds
Frostbite
Acute soft tissue injury
Circulatory disorders
Fractures
Bursitis
Periostitis
Myositis ossificans
Lack of tactile sensation / peripheral sensation
Infections
Skin disorders
Version 1
PERSONAL INFORMATION (select if/where appropriate):
Muscular/Skeletal problems: Back
Circulation: Heart
Cellulite
Aches/Pain
Blood pressure
Kidney problems
Nervous system: Migraine
Stiff joints
Fluid retention
Headaches
Tired legs
Varicose veins
Cold hands and feet
Tension
Stress
Depression
Immune system: Prone to infections
Regular antibiotic/medication taken? Yes
Herbal remedies taken? Yes
No
Do you work at a computer? Yes
No
If yes, which ones:
If yes, which ones:
No
If yes how many hours
Do you suffer/have you suffered from?
Dermatitis
Eczema
Psoriasis
Skin cancer
Allergies
Do you have or have you ever had an allergic reaction to materials used when taping and strapping:
Crepe
Elasticated adhesive/non adhesive
Adhesive tape
Second skin
Tubigrip
Underwraps
Other
Padding and felt
Zinc-oxide
Have you ever required taping and strapping previously? Yes
No
If yes, why?
Do you carry out any form of exercise at the moment?
Yes
IF YES:
What sort of exercise do you do? Gym
Exercise Classes
Yoga/Pilates
Running
Team sports
Swimming
Endurance
No
Walking
Weights/Resistance
Other
How long have you been exercising for? 1 month
2 months
3- 6 months
How often do you exercise at the moment – times per week: 1-2 times
7+
3-4 times
Client feedback:
Details of after/home care advice including recommendations for future treatment:
Client Signature.........................................................................
Student Signature.....................................................................
Date.............................
Version 1
Longer
5-6 times