PERSONAL DETAILS
Treatment Evidence Consultation Form
Level 3 Diploma in Sports Massage Therapy
Unit 455
College name: IMST
Client Details
College Number: 1392
Client Name
College
institute of Massage & Sports Therapy Ltd
Student
NameName:
:
Address
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:
How many units of these drinks do you consume per day?
Tea:
Coffee:
Fruit juice:
Water:
Do you suffer from food allergies? Yes
No
Soft drinks:
Others:
Do you smoke? No Yes
How many per day?
Do you drink alcohol? No
Yes
How many units per day?
Do you exercise? None
Occasional
Regular
Type:
What is your skin type? Dry Oily
Sensitive
Dehydrated
Do you suffer/have you suffered from: Dermatitis
Acne Eczema
Allergies
Hay Fever
Asthma
Skin cancer
Stress level: 1–10 (10 being the highest) and why
At work Why ?
At home
why ?
Psoriasis
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
( )
NO
( )
()
( )
( )
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)
( )
( )
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
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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___________________________
Date ___________________
Signed Client ____________________________
Date ____________________
Treatment two
Details of any conditions ticked _____________________________________________________
Signed Therapist___________________________
Date ___________________
Signed Client ____________________________
Date ____________________
Treatment 3
Details of any conditions ticked _____________________________________________________
Signed Therapist___________________________
Date ___________________
Signed Client ____________________________
Date ____________________
WRITTEN PERMISSION REQUIRED BY GP/SPECIALIST (which should be attached to the
consultation form):
Yes
No
PHYSICAL EXAMINATION
Name ____ _
________Treatment No ____
Date _____
Full Postural analysis of symmetry and examination
Observations:
Body Type :
Head
Shoulders:
Back:
Pelvis:
Legs:
Feet:
Body alignment/posture summary :
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
Name ____ _
________ Treatment No
Date _____
Each relevant active movement should be tested for Pain or Restriction as per the table below. If there is
any pain a pain scale of 1-10 should be used to determine the pain level.
Flexion
Extension Abduction Adduction Internal
rotation
External
rotation
R
Shoulder
L
shoulder
R Elbow
L Elbow
R Hip
L Hip
R Knee
L Knee
Back
Overview of client :
Posture & Range of movement findings, identifying areas of tension or pain
Goal of treatment
Side
flexion
Rotation
Palpation (choice of techniques, strokes, and why, how the client reacted to each technique)
How the client felt during & after the treatment:
Home care advice given:
Reflective practice: