STUDENT CASE FORM
Name:
Terrence Alexis
Address:
#6A Gopaul Street, Ext. #1, Diamond Village, San Fernando
Date of Birth/Age:
26/10/1972 / 50 yrs
Medical History:
Scoliosis, Tumor surgery under the left foot (5+ yrs ago), Nerve Damage,
Date:
26/08/2023
Signature of Client:
Terrence Alexis
ONLY ONE CLIENT PER SHEET. At each session, date and make comments on THIS FORM after
each session, have the client sign and date the form.
SUGGESTIONS
Note areas of tenderness on the foot chart in color and use numbers for degree of sensitivity (1= mild and
5 = extreme).
●
●
Note self help or homework given to client.
Follow up comments. Response to first session, ie; how they feel, reactions noted, etc.
● DO NOT DIAGNOSE - Do not use medical terms or diagnose, ie, swollen ankles, do not use the
term Edema.
● State client’s observation of how they feel, not your own, as it could be interpreted as diagnosing.
● Be sure to place word reflex after the area to which you are referring, ie; shoulder reflex and
stomach reflex.
Tenderness - 4
Tenderness - 3
Tenderness - 4
DATE
COMMENTS
Use additional sheets if needed.
26/08/2023 Pre-session: Client stated discomfort in the heel, prostate reflex and chest reflex
Post-session: Client claimed to have gained relief and said to have felt sleepy and gaseous during session
02/09/2023 Client stated that they have been more energetic since the last session. Client was
observed to be gaseous during session. They stated that their prostate reflex was
painful to the touch during session; but was resolved by the end of session.