Contents
Introduction ................................................................................................................ 1
Relaxation Massage Initial Consultation Form ........................................................... 2
Relaxation Massage Follow Up Form......................................................................... 8
Introduction
This booklet contains master copies of the Client Case Taking Sheets (CCTS) that
are required for the Certificate in Relaxation Massage. To use these forms, take a
photocopy of the form you require. Alternatively, you can download and print
electronic versions of each form from the Student Resources Centre area of the
College website. To locate the forms, login to the Student Resources Centre on the
bottom left of the home page and then use the left hand navigation menu to go to
‘Student Forms/Downloads’. This is can be found at the bottom of the menu.
Relaxation Massage Initial Consultation Form
Student Name: ______________________
Client Name: _______________________
Time _________ Duration of Massage__________ Date _____/_____/_____
BIOGRAPHICAL DATA * INDICATES INFORMATION THAT THE COLLEGE REQUIRES.
IN ORDER TO PROTECT CLIENT CONFIDENTIALITY, PLEASE BLANK OUT THE REST.
Clients Name*(*First only): _______________________
Address: _________________________________________________________________________________
Phone*: ___________________________________
Alternative Phone: _________________________
D.O.B*: ___________________________________
Age:______ Gender*: __________________________ __
Relationship Status*:_________________________
Children (Ages)*: ______________________________
Occupation*:________________________________
Since when*: _________________________________
Emergency Contact Person: __________________
Phone: ______________________________________
Relation to you: ____________________________
General Practitioner: ________________________
Phone:_______________________________________
Always ask the client for consent to contact their Doctor and if the client does not know their Doctor, or does
not have one please log this on the CCTS form.
Religion/Cultural Considerations*: _____________________________________________________________
GENERAL HEALTH
□ Very Good
□ Good
□ Fair
□ Poor
CLIENT GOAL
Remember the following:

Subjective, Objective, Assessment, Plan (SOAP)

What does the client want in this consultation - general relaxation, pain relief, tension relief?

Does your client have areas of pain or tension? Ensure that you document perceived cause, duration,
treatments tried, diagnosis, pain scale etc

Has the client had a massage or body work before, and if so was it helpful?
Please indicate areas of:


Tension in GREEN
Pain in RED
ABSOLUTE CONTRAINDICATIONS
Absolute Contraindications are conditions where a client cannot receive massage. Giving a massage to a client who
has an absolute contraindication can result in serious health risks for the client and/or the therapist. Some absolute
contraindications can cause death. Not all are permanent. Once a condition has cleared the client will be able to
receive a massage treatment.
□ Acute Bacterial / Viral conditions
□ Blood clotting disorders
□ Embolism
□ Heart Conditions
□ Renal problems
□ Pregnancy – first trimester
□ Acute inflammatory conditions
□ Cancer, specify
□ Fever / High temperature
□ Hypertension 160 / 100
□ Thrombosis
RELATIVE CONTRAINDICATIONS
Relative Contraindications are conditions where diagnosis, medication and other characteristics require the therapist
to take precautions and adapt and monitor the treatment to suit the client.
□ Allergies
□ Diabetes mellitus
□ Dizziness
□ Gout
□ Hepatitis
□ Hypotension
□ Multiple Sclerosis
□ Osteoarthritis
□ Rheumatoid arthritis
□ Asthma
□ Digestive problems
□ Epilepsy
□ Headaches
□ Hypertension (diagnosed, with consent)
□ Migraine
□ Numbness/tingling
□ Oedema
□ Stroke (rehabilitation)
140/
90
– 159/99
LOCAL CONTRAINDICATIONS
These are conditions involving a pathology related illness/disease or an acute injury. Caution must be exercised,
and the massage must be adapted to the condition. This is to ensure the safety of both client and the therapist. For
the client, the massage must be adjusted as to ensure it will not spread the condition, or further injure the client. For
the therapist, it is to ensure they do not contract the condition.
□ Eczema
□ Psoriasis
□ Fractures
□ Varicose veins
BLOOD PRESSURE AND MELANOMA
□ Last time BP was taken and reading
□ Family history of Hypertension
□ Family history of Hypotension
□ Are you aware of any new or changes to existing
moles?
□ Any bleeding / itchiness?
□ Family and / or personal history of skin cancer?
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Remember to check for the following:
Asymmetry
Border
Colour
Diameter – 6mm
Elevation
Enlargement
(ABCDEE)
Referral to Doctor
If you have ticked any of the above conditions, please ensure that you give more detail below, including
severity, duration, treatment tried, and consent from primary health provider where necessary.
ADDITIONAL INFORMATION:
MEDICATION / SUPPLEMENTS
Please also state the reason for, and duration of use.
LIFESTYLE
Work: Document the activity that the client predominantly does within her/his job, e.g.at computer 8.5hrs per day.
Family: Commitments, family activities - document if appropriate.
Exercise: Type of exercise, how long and how often.
Sleep: Length of time sleeping, broken or unbroken etc.
Energy levels: (1 – 10)
Stress levels: (1 – 10)
CLIENT DECLARATION – PLEASE READ CAREFULLY
This is an agreement between you and the client. Both to sign to legally cover all aspects of this consultation.
I, ________________________________________ (Client must write their name here), have given the student
practitioner accurate personal information, and I declare that I am in good health to receive a massage treatment. I
am aware that both myself, and the student practitioner both have the right to stop the treatment at any time. I also
give consent for my health information to be documented, and physical examinations and assessments to be
performed. I understand that a treatment plan will be created for me after agreement between myself and the
student practitioner.
Client Signature: _________________________________________
(Client must sign here)
Student Practitioner Signature: ____________________________
(Student must sign here)
Date: ____________________________
ASSESSMENT/MASSAGE ASSESSMENT
Includes observation and palpation of tissues relevant to client goal.
TREATMENT PLAN
Based on the information you have documented, what treatment is appropriate for this client today?
TREATMENT GIVEN
Massage - document modifications made according to client’s condition and palpatory findings, oils etc.
POST TREATMENT EVALUATION
Description of treatment - findings, client response to techniques used, what can be learnt?
CLIENT FEEDBACK
Please list all comments from the client stating what you have learnt from this feedback.
HOME EXERCISE / SELF HELP TECHNIQUES
Document any advice given to client, e.g. adequate hydration after treatment.
REFERRAL
If applicable, state who you have referred the client to.
FOLLOW UP DATE / TIME
REMINDERS / SELF REFLECTION
Areas needing research, things to ask your client or do for your client in the next appointment, how you felt about this
consultation - is there areas that need work etc
CLIENT CONSENT
I consent for this case study to be forwarded to the Naturopathic College of New Zealand where it will be assessed as part
of the student practitioner’s written course work. I understand that all my identifiable details will be erased before my notes
are sent to the College. I give my telephone number in the knowledge that the College may wish to contact me to confirm
the authenticity of the consultation.
Christian name (Only): _____________________ Signature: ______________________________________________
Date: ____________________________________ Telephone Number: ______________________________________
Student Name: ____________________________ NCNZ Student Number: __________________________________
Relaxation Massage Follow Up Form
Student Name: _______________________
Client Name: _______________________
Time _________ Duration of Massage__________ Date _____/_____/_____
EVALUATION OF PREVIOUS TREATMENT
Improvement of symptoms, energy levels, improved sleep, etc.
PRESENTING COMPLAINT AND CLIENT REQUIREMENTS
Please indicate areas of:
 Tension in GREEN
 Pain in RED
CLIENT DECLARATION – PLEASE READ CAREFULLY
This is an agreement between you and the client. Both to sign to legally cover all aspects of this consultation.
I, ________________________________________ (Client must write their name here), have given the student
practitioner accurate personal information, and I declare that I am in good health to receive a massage treatment. I am
aware that both myself, and the student practitioner both have the right to stop the treatment at any time. I also give
consent for my health information to be documented, and physical examinations and assessments to be performed. I
understand that a treatment plan will be created for me after agreement between myself and the student practitioner.
Client Signature: _________________________________________
(Client must sign here)
Student Practitioner Signature: ____________________________
(Student must sign here)
Date: ____________________________
ASSESSMENT/MASSAGE ASSESSMENT
Observation and palpation of tissues - any asymmetry, changes in skin texture, colour, heat, bruising, etc.
TREATMENT PLAN
Based on the information documented, what treatment is appropriate for this client today?
TREATMENT GIVEN
Massage – document modifications made according to client’s condition and palpatory findings.
POST TREATMENT EVALUATION AND CLIENT FEEDBACK
Description of treatment, what were the findings, how did the client respond to the techniques used and what can be learnt
from this?
HOME EXERCISE / SELF HELP TECHNIQUES
Document any advice given to client e.g. adequate hydration after treatment.
REFERRAL
If applicable, state who you have referred the client to.
FOLLOW UP DATE / TIME
ADDITIONAL INFORMATION