Client Consultation Form – Stone Therapy Massage
College Name: Client Name:
College Number: Address:
Student Number: Profession:
Date: Tel. No: Day
Age group: Under 20 20–30 30–40 40–50 50–60 60+
Lifestyle: Active Sedentary
Last visit to the doctor: 2 months ago
No. of children (if applicable): 2
Date of last period (if applicable): 2 weeks ago
CONTRAINDICATIONS 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):
Pregnancy Any dysfunction of the nervous system (e.g.
Cardio vascular conditions (thrombosis, phlebitis, Muscular sclerosis, Parkinson’s disease, Motor
hypertension, hypotension, heart conditions) neurone disease)
Haemophilia Bell’s Palsy
Any condition already being treated by a GP or Trapped/Pinched nerve (e.g. sciatica)
another complementary practitioner Inflamed nerve
Medical oedema Cancer
Osteoporosis Postural deformities
Arthritis Spastic conditions
Nervous/Psychotic conditions Kidney infections
Recent operations Slipped disc
Diabetes Undiagnosed pain
Asthma When taking prescribed medication
CONTRAINDICATIONS THAT RESTRICT TREATMENT (select if/where appropriate):
Contagious or infectious diseases Scar tissue (2 years for major operation and 6
Under the influence of recreational drugs or months for a small scar)
Diarrhoea and vomiting Hormonal implants
Skin diseases Abdomen (first few days of menstruation
Undiagnosed lumps and bumps depending how the client feels)
Localised swelling Haematoma
Varicose veins Recent fractures (minimum 3 months)
Pregnancy (abdomen) Cervical spondylitis
Cuts Gastric ulcers
Bruises After a heavy meal
Conditions affecting the neck
WRITTEN PERMISSION REQUIRED BY:
GP/Specialist Informed consent
Either of which should be attached to the consultation form.
PERSONAL INFORMATION (select if/where appropriate):
Muscular/Skeletal problems: Back Aches/Pain Stiff joints Headaches
Digestive problems: Constipation Bloating Liver/Gall bladder Stomach
Circulation: Heart Blood pressure Fluid retention Tired legs Varicose veins
Cellulite Kidney problems Cold hands and feet
Gynaecological: Irregular periods P.M.T Menopause H.R.T Pill Coil Other
Nervous system: Migraine Tension Stress Depression
Immune system: Prone to infections Sore throats Colds Chest Sinuses
Regular antibiotic/medication taken? Yes No If yes, which ones
Herbal remedies taken? Yes No If yes, which ones
Ability to relax: Good Moderate Poor
Sleep patterns: Good Poor Average No. of hours 8
Do you see natural daylight in your workplace? Yes No
Do you work at a computer? Yes No If yes how many hours 3
Do you eat regular meals? Yes No
Do you eat in a hurry? Yes No
Do you take any food/vitamin supplements? Yes No If yes, which ones - multi vitamin
How many portions of each of these items does your diet contain per day?
Fresh fruit: 2 Fresh vegetables: 2 Protein: 1 source? Fish or white meat
Dairy produce: 4 Sweet things: 2 Added salt: 3 Added sugar: 3
How many units of these drinks do you consume per day?
Tea: 4 Coffee: 4 Fruit juice: 2 Water: 0 Soft drinks: 1 Others: 0
Do you suffer from food allergies? Yes No Bingeing? Yes No Overeating? Yes No
Do you smoke? No Yes How many per day? 1-5
Do you drink alcohol? No Yes How many units per day? 2
Do you exercise? None Occasional Irregular Regular Types
What is your skin type? Dry Oily Combination Sensitive Dehydrated
Do you suffer/have you suffered from: Dermatitis Acne Eczema Psoriasis
Allergies Hay Fever Asthma Skin cancer
Stress level: 1–10 (10 being the highest)
At work 7 At home 4
The client presented with tension in her upper back and complained of feeling stressed.
Basalt stones and marble were used at the correct temperature
A visualisation technique was used to help her to relax and I performed techniques designed to
wake up the chakras
I wrapped the largest of the hot basalt stones in one layer of towelling and placed this over the
client's sacral region.
I proceeded to carry out the full massage routine adapting appropriately and paying particular
attention to the nodules and adhesions apparent in her upper back.
I performed closing techniques to end the treatment.
The client was given a glass of water to drink whilst discussing the after care advice.
My client said she felt extremely relaxed and very sleepy. She thoroughly enjoyed the warmth of the
treatment and would definitely have the treatment again
After/Home care advice given:
Advised the client to attend a further treatment in one week's time and continue with weekly
treatments for the next 3 sessions then reassess the situation.
I advised the client that in the short term she may experience a change in mood, but that this would
even out over the next 24-48 hours.
Additionally, the body may try to eliminate waste, so this was outlined to the client.
I explained that she may feel worse before she feels better, again this reaction is not uncommon,
I suggested that if she is working on the computer she tries to take small breaks
Relaxation is important for the rest of the day
Drink approximately 3-4 glasses of water and preferably no alcohol