Treatment Evidence Consultation Form
Level 4 Certificate in Sports Massage Therapy
Unit 458
TE NO_____________
College name:
Client name:
College Number
Address:
College
institute of Massage & Sports Therapy Ltd
Student
NameName:
:
Student number
College Number: 1392
Profession:
Date:Student Name: John O’Neill
Tel No day:
Eve
PERSONAL DETAILS
Age group: under 16
Under 20
Lifestyle: Active Sedentary
Last visit to the doctor:
GP Address:
No. Of children (if applicable):
Date of last period (if applicable):
20–3 0
30–40
40–50
50–60
60+
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: Are you pregnant or trying for a baby Yes
No
Nervous system: Migraine Tension Stress
Depression
Immune system: Prone to infections Sore throats Colds Chest
Sinuses _
Details
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
Do you see natural daylight in your workplace? Yes No
Do you work at a computer? Yes No If yes how many hours
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:
How many portions of each of these items does your diet contain per day?
Fresh fruit:
Fresh vegetables:
Protein:
source?
Dairy produce:
Sweet things:
Added salt:
Added sugar: 0
How many units of these drinks do you consume per day?
Tea:
Coffee:
Fruit juice:
0
Water:
Soft drinks:0
Do you suffer from food allergies? Yes
No
Do you smoke? No Yes
How many per day?
Do you drink alcohol? No
Yes
How many units per day? Only occasionally
Do you exercise? None
Occasional
Irregular
Regular
Type:
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) and why
At work Why ?
At home
why ?
Others:
Do you now, or have you recently suffered from any of the following conditions? YES
Contraindications that restrict treatment
Total Contraindications
Fever
( )
Any form of infectious disease
( )
Under the influence of recreational drugs or alcohol
( )
Diarrhoea and vomiting
( )
Localised
Skin diseases
Undiagnosed lumps and bumps
Localized swelling
Inflammation
Varicose veins
Pregnancy on the abdomen once permission has been given
Cuts, bruises, abrasions, open skin
Scar tissues – 2years for major operation, 6 months for minor
Sunburn
Hormonal implants
Abdomen for first few days of menstruation,
depending on how client feels
Haematoma
Hernia
Recent fractures- minimum 3 months
Cervical spondylitis
After a heavy meal
Gastric ulcers
Conditions affecting the neck
Any metal pins or plates
IUD (contraceptive Coil)
Any areas of loss of sensation (thermal and tactile sensitivity tests)
NO
( )
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GP / Medical or Specialist Permission
In circumstances where written medical permission cannot be obtained, clients must indemnify their condition
in writing prior to treatment
Pregnancy
( )
( )
Any condition already being treated by a GP or another practitioner
( )
( )
Cardio vascular conditions ( thromboisis, hlebitis, hypertension,
hypotension, heart - conditions)
( )
( )
Medical oedema
( )
( )
Haemophilia
( )
( )
Osteoporosis
( )
( )
Arthritis
( )
( )
Nervous/ psychotic conditions
( )
( )
Epilepsy
( )
( )
Recent operations
( )
( )
Diabetes
( )
( )
Asthma
( )
( )
Any dysfunction of the nervous system, Muscular sclerosis,
Parkinsons disease, motor neurone disease
( )
( )
Bells palsy
( )
( )
Trapped/pinched nerve
( )
( )
Inflamed nerve
( )
( )
Cancer
( )
( )
Postural deformities
( )
( )
Spastic conditions
( )
( )
Kidney infections
( )
( )
Whiplash
( )
( )
Slipped disc
( )
( )
Undiagnosed pain
When taking prescribed medication
Acute rheumatism
( )
( )
( )
( )
( )
( )
Please give details of condition, medication etc for any of the above that was ticked
I, the undersigned, hereby declare that the statements and particulars on this consultation card are true and
correct. It has been explained to me that ________________ is an unqualified student under tuition and
therefore I will not hold them or the Institute of Massage & Sports Therapy Ltd responsible for any injury,
damage or discomfort suffered during or as a result of the treatment. I further understand that a record of my
treatment will be submitted to her examining body for assessment. If fully consent to treatment under the above
conditions.
Treatment One
Details of any conditions ticked _____________________________________________________
______________________________________________________________________________
Signed Therapist___________________________
Signed Client ____________________________
Date ___________________
Date ____________________
Treatment Two
Details of any conditions ticked _____________________________________________________
______________________________________________________________________________
Signed Therapist___________________________
Signed Client ____________________________
Date ___________________
Date ____________________
Treatment Three
Details of any conditions ticked _____________________________________________________
______________________________________________________________________________
Signed Therapist___________________________
Signed Client ____________________________
Date ___________________
Date ____________________
Treatment Four
Details of any conditions ticked _____________________________________________________
______________________________________________________________________________
Signed Therapist___________________________
Signed Client ____________________________
Date ___________________
Date ____________________
WRITTEN PERMISSION REQUIRED BY GP/SPECIALIST (which should be attached to the
consultation form):
Yes
No
CURRENT COMPLAINT DETAILS
Pain Date of Onset
Duration
Description
Aggravated by
Eased by
Pain score
1
No pain
2
3
4
5
6
moderate
7
8
9
10
worst possible
History of Present Condition
Recurring Injury Yes
No
If yes, What treatment was previously undertaken? How long did the injury take to heal? Still ongoing?
Did you have any investigations? Yes
No
If yes, which ones:
PHYSICAL EXAMINATION
Full Postural analysis of symmetry and examination:
Observations:
Head:
Shoulders:
Back:
Pelvis:
Legs:
Feet:
Body alignment/posture:
Body Type:
Mark X for any areas of tension that the client experiences regularly
Mark ///// for any areas of adhesion or tension felt by the therapist on palpation
Treatment No_________________________
Date ____________________________
Joint Movement Tested: to include spinal range and movement of the upper and lower limbs
Pain is graded using the 0-10 pain scale, 0 = no pain, 10= unbearable.
ROM is graded as either the number of degrees of movement, or the % of normal ROM in comparison to the
healthy limb
Shoulder
Active
Passive
R
L
Pain/ ROM
Pain/ ROM
___________
__________
Flexion
R
Pain/ ROM
__________
L
Pain/ ROM
___________
Extension
__________
___________
___________
__________
Abduction
__________
___________
___________
__________
Adduction
__________
___________
___________
__________
Int rotation __________
___________
___________
__________
Ext rotation __________
___________
___________
__________
Empty Can test _______________________________________________________
Drop Arm Test ______________________________________________________
Elbow
Active
Passive
R
Flexion
R
L
Pain/ ROM Pain/ ROM
__________
____________
Pain/ ROM
Pain/ ROM
___________
__________
Extension ___________
____________
___________
__________
Supination ___________
____________
____________
__________
Pronation
____________
___________
____________
Tennis Elbow Test __________________________________
Golfer’s Elbow Test _________________________________
_________
L
Hip
Flexion
Active
R
L
Pain/ ROM
Pain/ ROM
___________ ____________
Passive
R
L
Pain/ ROM
Pain/ ROM
___________ __________
Extension ___________
____________
___________
__________
Abduction ___________
____________
___________
__________
Adduction
___________
____________
___________
__________
Int rotation ___________
____________
___________
__________
Ext rotation ___________
____________
___________
_________
Thomas Test __________________________________________________________
Knee
Active
R
Pain/ ROM
Flexion
Extension
___________
___________
L
Pain/ ROM
Passive
R
L
Pain/ ROM
Pain/ ROM
_____________
_____________
____________ ___________
____________ ___________
Medial ligament Test _______________________________________
Lateral Ligament Test _______________________________________
Anterior Cruciate Ligament Test _______________________________
Posterior Cruciate Ligament Test _______________________________
Apley’s Compression Test for Meniscus Damage __________________
Chondramalacia Patella Test (Clarke’s Sign )______________________
Runners Knee Test
_________________________________________
Ober’s Test ___________________________________________________
Ankle
Active
R
L
Pain/ ROM
Pain/ ROM
PlantarFlexion
DorsiFlexion
R
Pain/ ROM
Passive
L
Pain/ ROM
___________
_____________
__________
___________
___________
_____________
__________
__________
Inversion
___________
_____________
__________
__________
Eversion
____________
_____________
__________
__________
Thompsens Test for rupture of Achilles Tendon ______________________________
Test for Fallen Longitudinal Arch of Foot ___________________________________
Anterior Draw Test _____________________________________________________
Calcaneal Squeeze Test _________________________________________________
Wrist
Active
Passive
R
L
R
L
Pain/ ROM
Pain/ ROM
Pain/ ROM
Pain/ ROM
Flexion
____________
______________
___________
_________
Extension ____________
______________
____________ _________
Radial
Deviation ____________
______________
_____________ _________
Ulnar
Deviation ____________
_______________
______________
_________
Tinel Sign for Carpal Tunnel Syndrome ____________________________________
NECK MOVEMENTS
Active
Pain/ ROM
Pain/ ROM
Flexion _______________________________Extension _________________________
Left Side bending _______________________Right side bending___________________
Left Rotation __________________________Right Rotation ______________________
Adson’s Test ____________________________________________________________
Spurlings Test ___________________________________________________________
BACK MOVEMENTS
Active Movements
Pain/ ROM
Flexion
______________________
Extension
______________________
Left side flexion
______________________
Right side flexion
______________________
Left rotation
______________________
Right rotation
______________________
Gillet Test ___________________________________________________________
Slump Test __________________________________________________________
Faber’s Test __________________________________________________________
Straight Leg Raise for Herniated Disc: ____________________________________
Length Leg Check _____________________________________________________
Test for Shortness in Piriformis : __________________________________________
Thomas Test : _________________________________________________________
Muscle Tests- Isometric Strength Testing
Muscle Group
Right
Left
Muscle Bulk
Range of movement findings, identifying strengths and areas of improvement
Condition to be treatment:
Palpation and findings (choice of techniques, strokes, and why, how the client reacted to each technique)
Client Feedback:
Homecare/ aftercare advice to include injury management and injury prevention:
Reflective practice
Treatment Follow up Form
Treatment No _________________________ for this client
Range of Movement findings
Specialist Test Findings
Condition to be treated
Palpation and findings
Client feedback
Homecare advice
Reflective practice
Date ______________________