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Massage Assessment Form

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theloveboxxx2023
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441 views2 pages

Massage Assessment Form

Uploaded by

theloveboxxx2023
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Massage Assessment Form

Client Name: ___________________________________________________ Assessment Date: ______________________________


Chief Complaint: ___________________________________________________________ Date of Onset: ______________________
Brief Description of Onset: _______________________________________________________________________________________

Since onset, symptoms have been getting: Better Worse Staying the Same

Current Pain (0-10): ____/10 Pain range during past 3 days: ____/10 (at best), to ____/10 (at worst)

Pain or symptoms are: Constant Intermittent

Description of pain: Sharp Aching Stabbing Shooting


Dull Burning Throbbing Other: _______________________________________

What increases client's pain or other symptoms, and makes condition worse? (Mark all that apply)

Sitting Walking Coughing Specific position: _______________________________________


Standing Bending Exertion Activity or movement: __________________________________
Lying down Reaching Pressure Other: __________________________________________________

What decreases client's pain or other symptoms, and makes condition better? (Mark all that apply)

Sitting Rest Massage Specific position: _______________________________________


Standing Ice Stretching Activity or movement: __________________________________
Lying down Heat Medication Other: __________________________________________________

Has client seen other healthcare providers or tried other treatments for current problem? yes no

List treatments and results: __________________________________________________________________________________

Visual Assessment

Notes:

Posture:

Movement/ROM:

Gait:

Pain Tender point Adhesion Elevation


Hypertonicity Trigger point Swelling Rotation

Additional notes on visual assessment : ____________________________________________________________________________


_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
Palpation Assessment

Notes:

Consider characteristics of skin, warm/cool, dry/damp, subcutaneous tissues, muscle, fascia, tendons,
ligaments, lymph nodes, and areas of tenderness, weakness, soft tissue restrictions, swelling, etc.

Additional notes on palpation assessment : _______________________________________________________________________


_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________

Special tests: (+ / -) Test: _______________________ comments: ___________________________________________________

(+ / -) Test: _______________________ comments: ___________________________________________________

Assessment Summary:

SMART Goals

Client-Stated Goal: _________________________________________________________________________________________________


Long-Term Goal: ________________________________________________________________________ Achieve by: _______________
Short-Term Goals:
1. ______________________________________________________________________________________ Achieve by: _______________
2. ______________________________________________________________________________________ Achieve by: _______________

Treatment Plan: __________________________________________________________________________________________________


_________________________________________________________________________ Frequency / Duration:____________________

Recommended treatments:

Massage Hot Stones Myofascial Release Client Education


Cryotherapy Exercise Trigger Point Therapy Other: __________________________________
Heat Taping Stretching / ROM Other: __________________________________

Therapist Signature ____________________________ Date ______________

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