Client Consultation Form – Infant and Child Massage
College Name:
College Number:
Student Name:
Student Number:
Date:
Infant/Child Name:
Parent/Guardian Name:
Address:
Tel. No: Day
Eve:
GP:
Health Visitor:
INFANT/CHILD DETAILS:
Date of Birth:
Infant/child’s Sex:
Male
Female
Weight:
Average weight gain:
Height:
Type of birth:
Details of delivery:
Sleep pattern (select if/where appropriate):
Good
Average
Number of hours sleep:
Eating/feeding (select if/where appropriate):
Good
Average
Poor
Poor
CONTRAINDICATIONS REQUIRING MEDICAL PERMISSION – in circumstances where
medical permission cannot be obtained the parent/guardian must indemnify the condition in
writing prior to treatment (select if/where appropriate):
Recent operation/surgery
Dysfunction of the nervous system
Congenital heart condition
Epilepsy
Congenital dislocation of the hip
Asthma
Spastic conditions
CONTRAINDICTIONS THAT RESTRICT TREATMENT (select if/where appropriate)
Fever
Diarrhoea and vomiting
Contagious or infectious diseases
Recent immunisation (minimum 48 hours)
Recent fractures, sprains and swelling
Skin disorders
Recent haemorrhage
Inflammatory skin conditions
Jaundice
Skin allergies
Meningitis
Cuts and bruises
Childhood leukaemia
Unhealed navel
Osteoporosis/brittle bones
Infantile seborrhoeic dermatitis (cradle cap)
INFANT/CHILD INFORMATION
Digestive problems:
Constipation
Bloating
Immune system:
Prone to infections
Colds
Sore throats
Chest
Regular antibiotic/medication taken:
Herbal remedies taken:
Is the infant /child content:
Yes
No
Stomach
Sinuses
Sometimes
1
Sleep patterns:
Good
Poor
Average No. of hours
Does the infant/child have regular feeds/meals? Yes
No
Does the infant/child eat/drink quickly? Yes
No
Does the infant/child take any food/vitamin supplements? Yes
No
How much of each of these items does the infant/child’s diet contain?
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?
Milk: 0 Fruit juice: 0 Water: 0 Soft drinks: 0 Others: 0
Does the infant/child suffer from food allergies?
No
Yes
If yes, what foods are they?
What skin type does the infant/child have?
Dry
Sensitive
Other
Does the infant/child suffer/have suffered from?
Dermatitis
Psoriasis
Hay fever
Eczema
Allergies
Asthma
Reason for treatment:
Treatment details:
Feedback on how the infant/child reacted during and after the treatment:
After/Home care advice:
Student’s/Therapist’s Signature…………………………………………
Parent/Guardian’s Signature…………………………………………….
2
INFANT/CHILD MASSAGE FOLLOW UP SHEET
Treatment details:
Feedback on how the infant/child reacted during and after the treatment:
After/Home care advice:
Date of treatment……………………………………….
3