Client Consultation Form

iUBT296 – Indian head massage

Centre name:

Centre number:

Learner name:

Learner number:

Date:

Client name:

Address:

Profession:

Telephone number: Day:

Evening:

Personal details:
Age group: Under 20 ☐ 20 – 30 ☐ 30 – 40 ☐ 40 – 50 ☐ 50 – 60 ☐ 60+ ☐

Lifestyle: Active ☐ Sedentary ☐

Last visit to the
doctor:

GP Address:

Number of children:
(If applicable)
Date of last period:
(If applicable)

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 Contra-indications requiring medical permission – In circumstances where medical permission cannot be
obtained clients must give their informed consent in writing prior to treatment (select if/where
appropriate):
Cardiovascular conditions
(thrombosis, phlebitis,
hypertension, hypotension,
heart conditions)
Medical oedema
Nervous/psychotic conditions
Diabetes
Trapped/pinched nerve (e.g.
sciatica)
Inflamed nerve
Postural deformities
Slipped disc
Acute rheumatism
☐ Haemophilia
☐ Osteoporosis
☐ Epilepsy
☐ Asthma
☐ Inflamed nerve
☐ Cancer
☐ Spastic conditions
☐ Undiagnosed pain
☐
Any condition already being
☐ treated by a GP or another ☐
complementary practitioner
☐ Arthritis ☐
☐ Recent operations ☐
Any dysfunction of the nervous
system (e.g. Multiple sclerosis,
☐ ☐
Parkinson’s disease, Motor
neurone disease)
☐ Cancer ☐
☐ Postural deformities ☐
☐ Whiplash ☐
When taking prescribed
☐ ☐
medication

Contra-indications that restrict treatment – (Select if/where appropriate):

Contagious or infectious Under the influence of
Fever ☐ ☐ ☐
diseases recreational drugs or alcohol
Diarrhoea and vomiting ☐ Pediculosis capitis (head lice) ☐ Conjunctivitis ☐
Sycosis barbae ☐ Skin diseases ☐ Undiagnosed lumps and bumps ☐
Localised swelling ☐ Cuts ☐ Bruises ☐
Myalgic encephalomyelitis
Abrasions ☐ ☐ Psoriasis ☐
(Chronic fatigue syndrome)
Scar tissues(2 years for major
operation and 6 months for a ☐ Sunburn ☐ Hormonal implants ☐
small scar)
Recent fractures (minimum 3
☐ Cervical spondylitis ☐ After a heavy meal ☐
months)
Anaphylaxis ☐ Vertigo ☐ Adhesive capsulitis ☐
Bell’s palsy ☐ Tinnitus ☐ Migraine ☐
Earache ☐ Headaches ☐

Written permission required by (either of which should be attached to the consultation form):
GP/specialist ☐ Informed consent ☐

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 Personal information – (Select if/where appropriate):
Muscular/skeletal
Back ☐ Aches/pain ☐ Stiff joints ☐ Headaches ☐
problems:
Digestive Liver/gall
Constipation ☐ Bloating ☐ ☐ Stomach ☐
problems: bladder
Heart ☐ Blood pressure ☐ Fluid retention ☐ Tired legs ☐
Circulation: Kidney Cold hands and
Varicose veins ☐ Cellulite ☐ ☐ ☐
problems feet
Irregular
☐ P.M.T. ☐ Menopause ☐ H.R.T. ☐
Gynaecological: periods
Pill ☐ Coil ☐ Other:
Nervous system: Migraine ☐ Tension ☐ Stress ☐ Depression ☐
Prone to
☐ Sore throats ☐ Colds ☐ Chest ☐
Immune system: infections
Sinuses ☐
Regular antibiotic/ If yes, which
Yes ☐ No ☐
medication taken? ones:
Herbal remedies If yes, which
Yes ☐ No ☐
taken? ones:
Ability to relax: Good ☐ Moderate ☐ Poor ☐
Average no. of
Sleep patterns: Good ☐ Poor ☐
hours
Do you see natural
daylight in your Yes ☐ No ☐
workplace?
Do you work at a If yes, how
Yes ☐ No ☐
computer? many hours:
Do you eat regular
Yes ☐ No ☐
meals?
Do you eat in a
Yes ☐ No ☐
hurry?
Do you take any
If yes, which
food/vitamin Yes ☐ No ☐
ones:
supplements?
How many portions Protein and
Fresh fruit: Fresh vegetables:
of each of these source:
items does your
diet contain per
day? Dairy produce: Sweet things: Added salt: Added sugar:

How many units of Tea: Coffee: Fruit juice: Water:

these drinks do you
consume per day? Soft drinks: Other

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 Do you suffer from
Yes ☐ No ☐
food allergies?
Food bingeing Yes ☐ No ☐
Overeating Yes ☐ No ☐
How many per
Do you smoke? Yes ☐ No ☐
day:
Do you drink How many units
Yes ☐ No ☐
alcohol? per day:
None ☐ Occasional ☐ Irregular ☐ Regular ☐
Do you exercise?
Types

What is your skin Dry ☐ Oil ☐ Combination ☐

type? Sensitive ☐ Dehydrated ☐

Do you suffer/have Dermatitis ☐ Acne ☐ Eczema ☐ Psoriasis ☐

you suffered from: Allergies ☐ Hay fever ☐ Asthma ☐ Skin cancer ☐
Stress level 1-10:
(10 being the At work: At home:
highest)

Treatment details:

Client feedback:

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 Aftercare/Home care advice given:

Therapist/Learner signature: _______________________________________________________________________

Client signature: _________________________________________________________________________________

Date of treatment: _______________________________________________________________________________

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iUBT295 – Follow-up Sheet

Details of how the therapist conducted the treatment:

Details of how the client felt during and after the treatment:

Details of home care advice given:

Overall conclusion of the case study including reflective practice:

Date of treatment: _______________________________________________________________________________

iUBT296_Client Consultation Form_v1 Page 6 of 7

Document History

Version Issue Date Changes Role

v1 03/09/2019 First published Qualifications and Regulation Co-
ordinator

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