Screening

Demographic information is required as gender, age, occupation and contact numbers provide the practitioner with valuable information. There may be some risks associated with the client’s occupation that may need to be noted and enquired into. Information on health risk factors need to be noted and special needs recorded as they may require different attention and in some cases referral to a medical practitioner. Cardiovascular risk factors, medications and illness/injury information will all have an impact on the strokes used on the client. Read contraindications section. Listing common conditions that affect the client will help give a valuable insight into their medical history. Family history may provide insight into the client’s condition. If the client is going to be attending you on a regular basis it is a good idea to update the health screen every once in a while or if a new condition arises.
A pre-screening form provides the practitioner with valuable information and protects them and the client.

The following is a case history form developed with the students on the Health & Leisure Course with Massage at the Institute of Technology in Tralee, Co Kerry during the academic year 2009/2010 and is a work in progress:

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
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Other illnesses/imbalances at present?
________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Have you had a massage before?
How was massage of benefit in the past?
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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?
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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