Patient Name:

Address:
Phone No:
Date:
Age: Under 20
2030
3040
Lifestyle: Active
Sedentary
GP Address:

4050

5060

60+

Contraindications:
Pregnancy
Cardio vascular conditions
Haemophilia
Any condition being treated by a GP

Any dysfunction of the nervous system

Medical oedema
Osteoporosis
Arthritis

Cancer
Spastic conditions
Kidney infections
Whiplash
Slipped disc
Undiagnosed pain
Taking prescribed medication

Nervous/Psychotic conditions
Epilepsy
Recent operations
Diabetes

Bells Palsy
Inflamed nerve

Acute rheumatism

Restrictions to Treatment
Fever
Contagious or infectious diseases
Under the influence of drugs or alcohol
Diarrhoea and vomiting
Skin diseases
Undiagnosed lumps and bumps
Inflammation
Varicose veins
Pregnancy
Cuts

Bruises
Abrasions
Scar tissues
Sunburn
Hormonal implants
Abdominal pain
Haematoma
Hernia
Recent fractures
Cervical spondylitis
Gastric ulcers

Restrictions to Cryotherapy
Raynauds Phenomenon

Cold Erythema

Cold Hypersensitivity
Cold Urticaria

Cold Hemoglobinuria
Anesthesia
Hypothermia

As the person named above, I understand that the massage I receive should not be construed as a
substitute for medical examination, diagnosis, or treatment and massage therapists are not qualified
to diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of
the session given should be construed as such. Because massage should not be performed under
certain medical conditions, I affirm that I have stated all my known medical conditions, and answered
all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile
and understand that there shall be no liability on the therapists part should I fail to do so. If I

experience any pain or discomfort during this session, I will immediately inform the therapist so that
the pressure and/or strokes may be adjusted to my level of comfort. I also understand that CCTV
recording may take place for the safety of both parties during the massage. By signing this, I hereby
give my permission that the therapist can touch areas directly associated to the symptoms I have
presented to them.
Clients Signature:

Therapists Signature:

Date:

Worst Pain Possible

No Pain
Onset:
When:
How:
Progression:
Any Treatment:

Aggravating Factors Relieving Factors

Radiation:
Character:

Home Care Advice;

Frequency:

Stretch:

Observation:

Strengthen:

Active and Passive Movements:

Postural:

Palpations:

Heat:
Cold:

Clinical Opinion for the Complaint:

Treatment:

Therapist Signature:

Date:

SOAP FORM

Patient Name:

How patient has been since last

treatment

Follow Up #:
Date:
Pain: ____/10 improving, no change,
worsening
Any New Contraindications:
Observation:
Palpation:
A & P Movements:
Functional Tests:
Treatment Goals:

Treatment:

Patient to return: ___ days, _____ weeks, _____ months, recommend next
visit
Home care (FID - frequency, intensity, duration):
Stretch Strengthen
Postural Heat Cold

Date:
Therapist Signature:

SOAP FORM

Patient Name:

How patient has been since last

treatment

Follow Up #:
Date:
Pain: ____/10 improving, no change,
worsening
Any New Contraindications:
Observation:
Palpation:
A & P Movements:
Functional Tests:
Treatment Goals:

Treatment:

Patient to return: ___ days, _____ weeks, _____ months, recommend next
visit
Home care (FID - frequency, intensity, duration):
Stretch Strengthen
Postural Heat Cold

Date:

Therapist Signature:

SOAP FORM

Patient Name:

How patient has been since last

treatment

Follow Up #:
Date:
Pain: ____/10 improving, no change,
worsening
Any New Contraindications:
Observation:
Palpation:
A & P Movements:
Functional Tests:
Treatment Goals:

Treatment:

Patient to return: ___ days, _____ weeks, _____ months, recommend next
visit
Home care (FID - frequency, intensity, duration):
Stretch Strengthen
Postural Heat Cold

Date:
Therapist Signature:

SOAP FORM

Patient Name:

How patient has been since last

treatment

Follow Up #:
Date:
Pain: ____/10 improving, no change,
worsening
Any New Contraindications:
Observation:
Palpation:
A & P Movements:
Functional Tests:
Treatment Goals:

Treatment:

Patient to return: ___ days, _____ weeks, _____ months, recommend next
visit
Home care (FID - frequency, intensity, duration):
Stretch Strengthen
Postural Heat Cold

Date:
Therapist Signature: