TECHNICAL DATA SHEET RELAXING MASSAGE Nº____

City and date: ___________________________________________________

PERSONAL DATA:
First and Last Name: ______________________________________________ Sex: F___ M ___
Date of Birth: ______________________________________________ Age: __________
Identification: T.I _____ C.C ____ C.E ____ Other ____ Nº_________________ From: ____________
Profession or occupation: __________________________Dirección:_________________________________
Phone: _______________ Cell. _____________________ E-mail: ___________________________
In case of emergency call: _____________________________ Relationship: _____________________ Phone (s):
_______________________

DISEASES:

Arthritis ___ Arthrosis __ Headaches __ Cancer __ Diabetes __ Dermatitis __ Scoliosis __ Fractures __ Hemophilia
__ Hepatitis __ Hyperkyphosis __ Hypertension __ Hypotension __ Herniated discs __ Where? ________________
Hyperlordosis __Metal implants __Sciatic nerve __ Osteoporosis __ Osteomyelitis __Heart problems ____ which
ones? ______________ Surgeries __ Where? ________________
Sleeping hours______ do you practice any sport: ____ have you had this type of procedure done?____ with what
results?__________________
REASON FOR THE CONSULTATION:

HYPERSENSITIVITY TO ANY COSMETIC PRODUCT:

By contact __ By inhalation __ By inhalation __ By contact __ By inhalation __ By inhalation

Oil __ Cream __Talcum __Gel __ Essence Which? _______________________________

PROCEDURE:

Relaxing massage __ General __ Localized __ Where? ________________________

Sports Massage __ General __ Localized __ Where? ________________________
Lymphatic Drainage __ General __ Localized __ Where? ________________________

REMARKS:
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________
INFORMED CONSENT:

I__________________ identified (a) with citizenship card N°______________________ authorize the trainee
______________________ to perform the following procedure____________ and I release her from any liability that may
arise due to my own skin and outside the procedure itself I certify that I have read, I have been explained and I have
understood that the procedure has no processes, whose outcome depends on my care. My signature certifies that I agree with
the above.

____________________________ _____________________________

Signature of patient Signature of Esthetician

 APPOINTMENT CONTROL
DATE PROCEDURE ESTHETICIAN SIGNATURE

INDICATIONS CONTRAINDICATIONS

Disorders of the locomotor system: leg heaviness,  Feverish states or processes that run with fever.
swelling or overloading sensation, muscle discomfort...  Severe hemorrhagic alterations.
Nervous system disorders, stress, exhaustion, insomnia,  Phlebitis, thrombophlebitis and lymphagitis.
nervousness, chiromassage acts as a powerful relaxation  Unconsolidated bone fractures.
tool.  Decompensated heart disease (collect as m
information as possible from the patient and abov
Circulatory system disorders: deficiencies in venous and the corresponding medical diagnosis; if there is
lymphatic return circulation,(TMDL), swelling of the legs, doubt, we will not act).
overloading .....  Rheumatism in its acute phase.
Disorders of the digestive system, with massage  Tumor conditions and cancer.
techniques can help to a better functioning.  Infectious skin diseases.
 Acute trauma.
At the skin level, it improves its appearance and structure,  Muscle ruptures (fibers) and tendon rupt
stimulates circulation and promotes tissue oxygenation. (disinsertions) in their acute phase.
 Burns.
 Calcifications of soft structures.

CONCEPTS
Muscle spasms : disarrangement of the muscle fibers losing their elongation or movements and they become disarranged. Caused by: over fatigue, repetitive
movements, exaggerated and prolonged loads or sudden unexpected news of heavy loads, e.g.: 3 hours of exercise and did not take the muscle to its maximum
stretch: 3 hours of exercise and I did not take the muscle to its maximum stretch and it becomes saturated and accumulates toxic substances and lactic or
pyruvic acid is generated as these substances have become toxins, Lack of oxygenation in the muscle or by loss of fluids (mineral salts) producing nerve
irritation.

CONTRACTURE: rupture of some muscle fibers and they are encapsulated and generated by strong movements or fibromyalgia in this case the muscle does
not heal, there is no way to rearrange.
TEAR: Rupture of the muscle belly is broken and there is an internal bleeding and there is nothing that can join it again is wrapped in a layer called muscular
facet and loses mobility and leads to contracture if it is muscular there is not so much problem but if it is tendon only recovers in 10%.