Client Record Card

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First name*

Last name*

Email*

Multi-line address

Country/Region*

Address*

City*

Zip / Postal code*

Phone*

Emergency Contact Number*

Client Lifestyle Details

What sports/activities do you participate in that may have contributed to your current issues?*

Medical History

Have you visited a GP in the last 6 months? If yes please provide reasons.

Have you received a medical professional referral for treatment to be carried out?*

Yes

Are you currently taking any medication? If yes please give details.

Conditions that prevent treatment

Have you had any of the listed medical conditions within the last 6 months?*

Pregnancy

Asthma

Cardio Vascular Conditions i.e Hypertension.

Haemophilia

Trapped/Pinched Nerve

Dysfunctions of the nervous system e.g Stroke

Medical Oedema

Cancer

Arthritis

Inflamed Nerve

Nervous/Psychotic Conditions

Kidney Infections

Epilepsy

Whiplash

Recent Operations

Slipped Disc

Diabetes

Undiagnosed Pain

Acute Rheumatism

None of the above

Conditions that restrict treatment

Have you had any of the listed medical conditions within the last 6 months?*

Fever

Varicose Veins

Contagious/Infectious disease

Under influence of recreational drugs or alcohol

Diarrhoea or vomiting

Cuts/bruises

Skin diseases

Sunburn

Undiagnosed lumps and bumps

Hormonal implants

Localised swelling

Abdomen (menstruation)

Inflammation

Hernia

Cervical Spondylitis

Recent fracture (within 3 months)

Gastric ulcers

None of the above

Do you give consent to be examined by your therapist prior to massage treatment?*

Yes

Do you give consent for massage treatment*

Yes

Pre Examination Details

*To be completed by Therapist

Which area of the body is to be treated?

Proposed Massage techniques

Post Examination Details

*To be completed by Therapist

Observations:

Comfortable movement patterns:

Palpation:

After subjective findings, which area of the body is to be treated?

Actual techniques used:

Post treatment stretches and advice given:

Penylan Library and Community Centre

Pen-Y-Lan Rd, Penylan, Cardiff CF23 5HW

07423 193821

movewellsmt@gmail.com

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