Sports Massage Case Study

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Client Consultation Form – Sports Massage

College Name:
College Number:
Student Name:
Student Number:
Date:

Client Name: Steve
Address:

Profession:
Tel. No: Day
Eve

PERSONAL DETAILS
Age group: Under 20 0 20–30 0 30–40 0 40–50 1 50–60 0 60+ 0 Lifestyle: Active 0 Sedentary 0
Last visit to the doctor:
GP Address:
No. Of children (if applicable):
Date of last period (if applicable):

CONTRAINDICATIONS (select if/where appropriate):
Never treat unless the injury has been diagnosed and treatment has been recommended by a medical practitioner.
Pregnancy
Cardio vascular conditions (thrombosis, phlebitis, hypertension, hypotension, heart conditions) 0 Haemophilia 0
Any condition already being treated by a GP or another health professional, e.g. Physiotherapist, Osteopath, Chiropractor, Coach 0 Medical oedema 0
Osteoporosis 0
Arthritis 0
Nervous/Psychotic conditions 0
Epilepsy 0
Recent operations 0
Diabetes 0
Asthma 0
Any dysfunction of the nervous system (e.g. Muscular sclerosis, Parkinson’s disease, Motor neurone disease) 0 Bells Palsy 0
Trapped/Pinched nerve (e.g. sciatica)
Inflamed nerve 0
Cancer 0
Postural deformities 0
Spastic conditions 0
Kidney infections 0
Whiplash 0
Slipped disc 0
Undiagnosed pain 0
When taking prescribed medication 0
Acute rheumatism 0

CONTRAINDICATIONS THAT RESTRICT TREATMENT (select if/where appropriate): Fever 0
Contagious or infectious diseases 0
Under the influence of recreational drugs or alcohol 0
Diarrhoea and vomiting 0
Skin diseases 0
Undiagnosed lumps and bumps 0
Localised swelling 0
Inflammation 0
Varicose veins 0
Pregnancy (abdomen) 0
Cuts 0
Bruises
Abrasions 0
Scar tissues (2 years for major operation and 6 months for a small scar) 0 Sunburn 0
Hormonal implants 0
Abdomen (first few days of menstruation depending how the client feels) 0 Haematoma 0
Hernia 0
Recent fractures (minimum 3 months) 0
Cervical spondylitis 0
Gastric ulcers 0
After a heavy meal 0

WRITTEN PERMISSION REQUIRED BY GP/SPECIALIST (which should be attached to the consultation form): Yes 0No 0
PERSONAL INFORMATION (select if/where appropriate):
Muscular/Skeletal problems: Back0 Aches/Pain1 Stiff joints0 Headaches0 Digestive problems: Constipation0 Bloating0 Liver/Gall bladder0 Stomach0 Circulation: Heart0 Blood pressure0 Fluid retention0 Tired legs0 Varicose veins0 Cellulite0 Kidney problems0 Cold hands and feet0

Gynaecological: Irregular periods0 P.M.T0 Menopause0 H.R.T0 Pill0 Coil0 Other:
Nervous system: Migraine0 Tension0 Stress1 Depression0
Immune system: Prone to infections0 Sore throats0 Colds0 Chest0 Sinuses0 Regular antibiotic/medication taken? Yes 0 No 1 If yes, which ones: Herbal remedies taken? Yes0 No1 If yes, which ones:

Ability to relax: Good0 Moderate1 Poor0
Sleep patterns: Good1 Poor0 Average No. of hours 7
Do you see natural daylight in your workplace? Yes 1 No0
Do you work at a computer? Yes1 No0 If yes how many hours 1 Do you eat regular meals? Yes1 No1
Do you eat in a hurry? Yes0 No1
Do you take any food/vitamin supplements? Yes1 No0 If yes, which ones: multi minerals and vitamins How many portions of each of these items does your diet contain per day? Fresh fruit: 5 Fresh vegetables: 3 Protein: 1 source? meat/fish Dairy produce: 0 Sweet things: 0 Added salt: 0 Added sugar: 0 How many units of these drinks do you consume per day?

Tea: 0 Coffee: 0 Fruit juice: 3 Water: 5 Soft drinks: 0 Others: 3 Do you suffer from food allergies? Yes0 No1 Bingeing? Yes0 No1 Overeating? Yes0 No1
Do you smoke? No 1 Yes 0 How many per day? 0
Do you drink alcohol? No0 Yes1 How many units per day? 2 Do you exercise? None0 Occasional0 Irregular0 Regular0 Type: gym, swimming, cycling, tennis, yoga What is...
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