Client Record Card

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?

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

No

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

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

Yes

No

Do you give consent for massage treatment

Yes

No

*To be completed by Therapist

Which area of the body is to be treated?

Proposed Massage techniques

*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:

Are you happy to receive occasional communications including offers, news and updates?