Client Consultation Form – Stone Therapy Massage
College Name:
College Number:
Student Name:
Student Number:
Date:
PERSONAL DETAILS
Age group: Under 20
20–30
30–40
40–50
Lifestyle: Active
Sedentary
Last visit to the doctor: 2 months ago
GP Address:
No. of children (if applicable): 2
Date of last period (if applicable): 2 weeks ago
Client Name:
Address:
Profession:
Tel. No: Day
Eve
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.
Muscular sclerosis, Parkinson’s disease, Motor
Cardio vascular conditions (thrombosis, phlebitis,
neurone disease)
hypertension, hypotension, heart conditions)
Bell’s Palsy
Haemophilia
Trapped/Pinched nerve (e.g. sciatica)
Any condition already being treated by a GP or
another complementary practitioner
Inflamed nerve
Medical oedema
Cancer
Osteoporosis
Postural deformities
Arthritis
Spastic conditions
Nervous/Psychotic conditions
Kidney infections
Epilepsy
Whiplash
Recent operations
Slipped disc
Diabetes
Undiagnosed pain
Asthma
When taking prescribed medication
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
Conditions affecting the neck
Version 3
(select if/where appropriate):
Abrasions
Scar tissue (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
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 8
Do you see natural daylight in your workplace? Yes
No
Do you work at a computer? Yes
No
If yes how many hours 3
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 - multi vitamin
How many portions of each of these items does your diet contain per day?
Fresh fruit: 2 Fresh vegetables: 2 Protein: 1 source? Fish or white meat
Dairy produce: 4 Sweet things: 2 Added salt: 3 Added sugar: 3
How many units of these drinks do you consume per day?
Tea: 4 Coffee: 4 Fruit juice: 2 Water: 0 Soft drinks: 1 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? 2
Do you exercise? None
Occasional
Irregular
Regular
Types
What is your skin type? Dry
Oily
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 7 At home 4
Treatment details:
The client presented with tension in her upper back and complained of feeling stressed.
 Basalt stones and marble were used at the correct temperature
 A visualisation technique was used to help her to relax and I performed techniques designed to
wake up the chakras

I wrapped the largest of the hot basalt stones in one layer of towelling and placed this over the
client's sacral region.
 I proceeded to carry out the full massage routine adapting appropriately and paying particular
attention to the nodules and adhesions apparent in her upper back.
 I performed closing techniques to end the treatment.
 The client was given a glass of water to drink whilst discussing the after care advice.
Client feedback:
My client said she felt extremely relaxed and very sleepy. She thoroughly enjoyed the warmth of the
treatment and would definitely have the treatment again
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After/Home care advice given:
 Advised the client to attend a further treatment in one week's time and continue with weekly
treatments for the next 3 sessions then reassess the situation.
 I advised the client that in the short term she may experience a change in mood, but that this would
even out over the next 24-48 hours.
 Additionally, the body may try to eliminate waste, so this was outlined to the client.
 I explained that she may feel worse before she feels better, again this reaction is not uncommon,

I suggested that if she is working on the computer she tries to take small breaks
 Relaxation is important for the rest of the day
 Drink approximately 3-4 glasses of water and preferably no alcohol
Student’s/Therapist’s Signature………………………………………….
Client’s Signature…………………………………………………………..
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