Treatment Evidence Consultation Form
Level 4 Certificate in Sports Massage Therapy
Unit 419
College name: Institute of Massage & Sports Therapy
Client name: Mary Smith
College Number: 1392
Address: 6, the downs, castletroy, limerick
College
institute of Massage & Sports Therapy Ltd
Student
NameName:
:
Student number
Collegehairdresser
Number: 1392
Profession:
Name:
Date:Student
17th June
2013John O’Neill
Tel No day: 0872588987
Eve
PERSONAL DETAILS
Age group: under 16
Under 20
20–3 0
30–40
Lifestyle: Active Sedentary x
Last visit to the doctor: 6 months
x ago for a chest infection
GP Address: Dr Matt Kiely, annacotty,
co limerick
x
No. Of children (if applicable):2
Date of last period (if applicable): 12th June 2013
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 aches and pains especially in neck and shoulders, headaches too and occasional colds
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 : 7 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:
1
Fresh vegetables: 1
Protein:
2
source? Meat, fish
Dairy produce: 3
Sweet things: 2
Added salt:
1
Added sugar: 0
How many units of these drinks do you consume per day?
Tea: 4
Coffee: 2
Fruit juice:
0
Water: 1 litre 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: walking
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 - 6
Why ? short staffed and expected to turn over clients quickly
At home 4
why ? two small kids, so no time off
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
( )
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
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 _____Rachel MCCarthy___________ 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
ORAL ASSESSMENT
Pain Date of Onset : 12th June 2013
Duration : pain has been on and off since- can last up
to an hour at a time
Description - dull nagging pain in top of right shoulder - can cause a headache
Aggravated by_ holding the arm above the head- blowdrying
Pain score
1
No pain
2
3
4
5
6
7
moderate
Eased by : paracetamol or heat
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:
VISUAL ASSESSMENT
Full Postural analysis of symmetry and examination:
Observations: Mary seems self conscious and nervous- a little pale
Head: right ear lower than left, head turned slightly to the right
Shoulders: right shoulder higher than left
Back: slight scolosis, towards the right
Pelvis: even
Legs: even
Feet: even- no sign of fallen arches etc
Body alignment/posture:
Body type – Endomorph
Right ear lower
Right shoulder higer
XX
XX
X
X = area of pain
///////= area of adhesions and muscle tension
Date _____17th June 2013_____________________
Treatment No_____1____________________
Pain is graded using the 0-10 pain scale, 0 = no pain, 10= unbearable. ROM is graded as degrees of movement.
Shoulder
Active
Flexion
R
Pain/ ROM
05 160’
Passive
R
Pain/ ROM
0/5 170’
L
Pain/ ROM
0/5 180’
L
Pain/ ROM
0/5 180’
Extension
0/5 45’
0/5 50’
0/5 50’
0/5 50’
Abduction
3/5 145’
0/5 170’
0/5 160’
0/5 170’
Adduction
0/5 35’
0/5 45’
0/5 45’
0/5 45’
Int rotation
1/5 30’
0/5 80’
0/5 60’
0/5 85’
Ext rotation _ 0/5 70’
0/5 80’
0/5 70’
0/5 80’
Empty Can test ___negative________________________________________________
Drop Arm Test ___________________________________________________________
Cross over Test__________________________________________________________
Speeds Test ____________________________________________________________NECK MOVEMENTS
Active
Pain/ ROM
Pain/ ROM
Flexion
3/5 40’
Left Side bending 2/5 10’
Extension 0/5
55’
Right side bending 2/5 15’
Left Rotation 2/5 50’
Right Rotation 1/5 60’
Spurlings test _____________________________________________
Adsons Test
___________________________________________
Muscle Tests- Isometric Strength Testing
Muscle Group
Right
Upper trapezius
Stronger by 20%
Muscle Bulk
Left
Weaker in comparison
More bulk and definition on
right shoulder and right side of
neck
Range of movement findings, identifying strengths and areas of improvement
Mary has difficulty in performing active shoulder flexion and abduction. She has the majority of pain and
restriction on active neck movements, flexion and left rotation and left side flexion.
Condition to be treatment: right shoulder/neck tension- overuse due to occupation
How client felt since the last visit
Na
Palpation (choice of techniques, strokes, and why)
I did plenty of effleurages and petrissages to relax tissues and begin to break up general muscle tension in
upper trapezius, splenius capitis and levator scapulae. Myofascial release alto worked well here. Frictions were
applied to trigger points and adhesions in the levator scapulae. Hyperaemia noted very quickly Lots of
effleurage to finish
Client Feedback: mary found some of the techniques tender but described it as a good sort of pain. She felt
tired but relaxed on completion of the treatment
Homecare/ aftercare advice to include injury management and injury prevention:
- Area could be stiff the following day
- Apply heat for 10-15 minutes twice daily
- Gentle mobilisation exercises and stretches for the neck- side flexion, side rotation and flexion
- Be aware of posture in work and try to avoid blow drying for the next week where possible
- Drink plenty of water
Lecturer’s / Therapist Signature ……………………………………
Client Signature………………………
Treatment No_____2___________________
Date _____20th June 2013_____________________
Pain is graded using the 0-10 pain scale, 0 = no pain, 10= unbearable. ROM is graded as degrees of movement
Shoulder
Active
Passive
R
Pain/ ROM
0/5 175’
Flexion
R
Pain/ ROM
0/5 170’
L
Pain/ ROM
0/5 180’
Extension
0/5 50’
0/5 50’
0/5 50’
0/5 50’
Abduction
2/5 155’
0/5 170’
0/5 165’
0/5 170’
Adduction
0/5 40’
0/5 45’
0/5 45’
0/5 45’
Int rotation 1/5 50’
0/5 85’
0/5 65’
0/5 80’
Ext rotation 0/5 75’
0/5 80’
0/5 75’
0/5 80’
NECK MOVEMENTS
Active
Pain/ ROM
L
Pain/ ROM
0/5 180’
Pain/ ROM
Flexion
2/5 50’
Extension
0/5 60’
Left Side flexion
1/5 30’
right side flexion
1/5 20’
Left rotation
1/5 60’
right rotation
Muscle Tests- Isometric Strength Testing
Muscle Group
Right
Upper trapezius
Stronger by 20%
Muscle Bulk
1/5 60’
Left
Weaker in comparison
More bulk and definition on
right shoulder and right side of
neck
Range of movement findings, identifying strengths and areas of improvement
There has been some improvements in pain levels and in mobility. Mary has found the exercises good and the
heat to be very soothing.
Condition to be treatment: right shoulder/neck tension- overuse due to occupation
How client felt since the last visit
Mary found the heat pack to be a great help. She was a bit stiff and sore for two days after treatment but then it
eased. She has beren doing the mobilisations and stretches and finds it feels looser.
Palpation (choice of techniques, strokes, and why)
Area felt much more pliable today. Effleurages, petrissages and frictions as before. Introduced some NMT
which worked well to levator scapulae. Soft tissue release performed on upper trapezius with Mary bringing her
neck into flexion. MET to upper trapezius also very effective
Client Feedback: mary was amazed by the NMT- couldn’t believe the pain would ease so quickly. Loved the
feel of the STR also.
Homecare/ aftercare advice to include injury management and injury prevention:
- Continue to apply heat for 10-15 minutes twice daily
-
-
Gentle mobilisation exercises and stretches for the neck- side flexion, side rotation and flexioncontinue with exercises, but add in a levator scapula stretch by bringing the neck into flexion, left
rotation and left side flexion
Be aware of posture in work and try to avoid blow drying for the next week where possible
Drink plenty of water and increase fruit and veg intake
Lecturer’s / Therapist Signature ……………………………………
Client Signature………………………