Docstoc

Sample Client Consultation Form - Infant_child Massage

Document Sample
Sample Client Consultation Form - Infant_child Massage Powered By Docstoc
					                   Client Consultation Form – Infant and Child Massage

      College Name:                                 Infant/Child Name:
      College Number:                               Parent/Guardian Name:
      Student Name:                                 Address:
      Student Number:
      Date:                                         Tel. No: Day
                                                            Eve:
                                                    GP:
                                                    Health Visitor:


INFANT/CHILD DETAILS:
Date of Birth:
Infant/child’s Sex:      Male         Female
Weight:         Average weight gain:
Height:
Type of birth:
Details of delivery:
Sleep pattern (select if/where appropriate):
Good                              Average                         Poor
Number of hours sleep:
Eating/feeding (select if/where appropriate):
Good                              Average                         Poor

CONTRAINDICATIONS REQUIRING MEDICAL PERMISSION – in circumstances where
medical permission cannot be obtained the parent/guardian must indemnify the condition in
writing prior to treatment (select if/where appropriate):
Recent operation/surgery                             Dysfunction of the nervous system
Congenital heart condition                           Epilepsy
Congenital dislocation of the hip                    Asthma
Spastic conditions

CONTRAINDICTIONS THAT RESTRICT TREATMENT (select if/where appropriate)
Fever                                  Diarrhoea and vomiting
Contagious or infectious diseases      Recent immunisation (minimum 48 hours)
Recent fractures, sprains and swelling Skin disorders
Recent haemorrhage                     Inflammatory skin conditions
Jaundice                               Skin allergies
Meningitis                             Cuts and bruises
Childhood leukaemia                    Unhealed navel
Osteoporosis/brittle bones             Infantile seborrhoeic dermatitis (cradle cap)

INFANT/CHILD INFORMATION
Digestive problems:
Constipation                      Bloating                        Stomach
Immune system:
Prone to infections               Colds                           Sinuses
Sore throats                      Chest
Regular antibiotic/medication taken:
Herbal remedies taken:
Is the infant /child content:
Yes                               No                              Sometimes




                                                1
Sleep patterns:
Good                                Poor                           Average No. of hours
Does the infant/child have regular feeds/meals? Yes         No
Does the infant/child eat/drink quickly? Yes             No
Does the infant/child take any food/vitamin supplements? Yes        No
How much of each of these items does the infant/child’s diet contain?
Fresh fruit: 0 Fresh vegetables: 0 Protein: 0 source?
Dairy produce: 0 Sweet things: 0 Added salt: 0 Added sugar: 0
How many units of these drinks do you consume per day?
Milk: 0 Fruit juice: 0 Water: 0 Soft drinks: 0 Others: 0
Does the infant/child suffer from food allergies?
No       Yes
If yes, what foods are they?
What skin type does the infant/child have?
Dry                                 Sensitive                      Other
Does the infant/child suffer/have suffered from?
Dermatitis                          Psoriasis                      Hay fever
Eczema                              Allergies                      Asthma

Reason for treatment:



Infant/child profile:



Details of how the therapist conducted the treatment:



Details of how the infant/child reacted during and after the treatment:



Details of home care advice given:



Overall conclusion of the case study including reflective practice:




Student’s/Therapist’s Signature…………………………………………


Parent/Guardian’s Signature…………………………………………….




                                               2
                           INFANT/CHILD MASSAGE FOLLOW UP SHEET

Details of how the therapist conducted the treatment:



Details of how the infant/child reacted during and after the treatment:



Details of home care advice given:



Overall conclusion of the case study including reflective practice:




Date of treatment……………………………………….




                                               3

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:142
posted:11/3/2011
language:English
pages:3