Case History Form

Section 1: Demographic Information
Surname:¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬ Name:

Age: Date of Birth:
Address:
Occupation:

Home number: Mobile:
Doctors name: Doctor’s Number:
Person to Contact in an Emergency:
Contact number:
**Living Arrangements: Married/ single/ separated/ co-habiting
Children:
Friends & Family:

Section 2: Lifestyle information
What are your hobbies and interests:

What type of exercise do you engage in?
How often?

Do you sleep well?

How would you describe your diet?

On a scale of 1 to 10 with 1 being lowest and 10 highest, how would you rate your current levels of stress?

How do you manage stress?

What are your smoking patterns?

What are your drinking patterns?

Section 3: Needs Assessment:
Why have you come for massage? Or why are you here today? Present condition/Illness
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Other illnesses/imbalances at present?
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Have you had a massage before?
How was massage of benefit in the past?
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VISUAL DIAGNOSIS:

Past Medical History:

Family history:

Section 4: Health Overview:
Lungs & respiratory system:
Skin:
Abdomen: Colon: Digestion:
Liver and Gall Bladder:
Heart/Circulation:
Extremities:
Endocrine System:
Nervous system:
Eyes:
Ears:
Nose:
Throat:
Immune System:
Allergies:
Genito – Urinary:

Please indicate if you suffer or have suffered from any of the following:

Epilepsy - referral Yes [ ] No [ ]
Asthma Yes [ ] No [ ]
Cancer - type and referral Yes [ ] No [ ]
Tumour, growth, cyst, cancer Yes [ ] No [ ]
Skin condition - depth, creams and treatment Yes [ ] No [ ]
Bruised Tissues Yes [ ] No [ ]
Scar tissue Yes [ ] No [ ]
Thrombosis - referral Yes [ ] No [ ]
Diabetes Yes [ ] No [ ]
Muscle, joint or back disorder Yes [ ] No [ ]
Treated broken bone Yes [ ] No [ ]
Pregnant or have been in past three months Yes [ ] No [ ]
Osteoporosis Yes [ ] No [ ]

Section 5 - On the Day Clearance
This section is designed to ensure you have an enjoyable and relaxing massage.
1. Have you eaten a heavy meal in the last 3 hours?
2. Have you taken drugs or alcohol in the last 24 hours?
3. Have you had major surgery in the past 12 months or
minor surgery in the past 6 months?
4. Do you have any injuries at present?
5. Have you a high temperature?
6. Any unexplained swelling or tenderness?
7. Are you on any medication?
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Any other information you would like the therapist to know before starting treatment
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Client Therapist
Signed: _________________________ Signed: _________________________

Date _________________________ Date _________________________

TACTILE DIAGNOSIS:

PLANNED TREATMENT: (Include time guide)

ACTUAL TREATMENT:

GENERAL OBSERVATIONS and FOLLOW_UP