Sports Massage Case Study
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)
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)