Client Consultation Form Holistic Massage

Transcription

1 Client Consultation Form Holistic Massage College Name: College Number: Student Name: Student Number: Date: 05/11 Client Name: Mrs MB Address: Derby Profession: Management Accountant Tel. No: Day Eve PERSONAL DETAILS Age group: Under Lifestyle: Active Sedentary Regular exercise undertaken and she usually walks to work Last visit to the doctor: Consulted a local physiotherapist about back pain when it occurred. Did not visit the doctor as she felt that a physiotherapist would offer more help. GP Address: Derby No. of children (if applicable): 0 Date of last period (if applicable): 29/10 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 Cardiovascular conditions (thrombosis, phlebitis, hypertension, hypotension, heart conditions) Haemophilia Any condition already being treated by a GP or another complementary practitioner Medical oedema Osteoporosis Arthritis Nervous/Psychotic conditions Epilepsy Recent operations Any dysfunction of the nervous system (e.g. Multiple sclerosis, Parkinson s disease, Motor neurone disease) Bells Palsy Trapped/Pinched nerve (e.g. sciatica) Inflamed nerve Cancer Postural deformities Spastic conditions Kidney infections Whiplash Slipped disc Undiagnosed pain When taking prescribed medication Acute rheumatism Diabetes Asthma Mrs MB is not suffering any contraindications that require medical permission but has experienced intermittent back pain. The treatment has been fully explained and she has signed an informed consent form. CONTRAINDICTIONS THAT RESTRICT TREATMENT (select if/where appropriate): Fever Bruises Contagious or infectious diseases Abrasions Under the influence of recreational drugs or Scar tissues (2 years for major operation and 6 alcohol months for a small scar) Diarrhoea and vomiting Sunburn Skin diseases Hormonal implants Undiagnosed lumps and bumps Cervical spondylitis Localised swelling Gastric ulcers Inflammation Abdomen (first few days of menstruation Varicose veins depending how the client feels) Pregnancy (abdomen) Haematoma Cuts Hernia Recent fractures (minimum 3 months)

2 After a heavy meal Conditions affecting the neck Mrs MB is not suffering from any contraindications that restrict treatment 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 Client experiences intermittent back stiffness. She consulted a physiotherapist to help her deal with a problem resulting from over training in August. Digestive problems: Constipation Bloating Liver/Gall bladder Stomach Client suffers bloating associated with menstruation occasionally Circulation: Heart Blood pressure Fluid retention Tired legs Varicose veins Cellulite Kidney problems Cold hands and feet Client has light cellulite deposits on thighs. Therapist observations note that the client has very toned thighs but poor circulation in the area. 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 1 Do you see natural daylight in your workplace? Yes No Do you work at a computer? Yes No If yes, how many hours? 8 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? How many portions of each of these items does your diet contain per day? Fresh fruit: 1 Fresh vegetables: 4 Protein: 2 source? Meat, fish, cheese Dairy produce: 0 Sweet things: 1 Added salt: 0 Added sugar: 0 How many units of these drinks do you consume per day? Tea: 0 Coffee: 6 Fruit juice: 1 Water: 0 Soft drinks: 0 Others: 1 Client does not drink any water, apart from that contained within coffee and herbal tea Do you suffer from food allergies? Yes No Bingeing? Yes No Overeating? Yes No Do you smoke? No Yes How many per day? 0 Do you drink alcohol? No Yes How many units per day? 1 Client often has a glass of red wine in the evening Do you exercise? None Occasional Irregular Regular Types: Usually walking, running, cycling as part of an ongoing regime. Currently not exercising due to back stiffness/pain What is your skin type? Dry Oil Combination Sensitive Dehydrated Client feels that skin is becoming drier with age. She does not take any oil based supplements such as evening primrose oil. Do you suffer/have you suffered from: Dermatitis Acne Eczema Psoriasis Allergies Hay Fever Asthma Skin cancer Client suffers mild eczema on her hands occasionally Stress level: 1 10 (10 being the highest) At work 4 At home 2 Client rates her stress levels as low for both work and home. She has a very positive approach to life generally.

3 Client Profile Mrs MB is 42 years old. She is married and has no children although she is stepmother to 4 grown up children. She lives with her husband who is an engineer. She is employed full time as a Management Accountant. Her office is based a short distance from her home so she is able to walk to work most days, depending on the weather. Last year was stressful for her she was made redundant from a job that she really enjoyed. However, she was quickly re-employed within a month, but she had some misgivings about her new job. Compared to previous jobs she felt under-utilised and this became a source of frustration for her. Consequently, after only four months she resigned. Due to the high demand for her skills, she found a new job and started at a new company within less than a month. In the middle of all of the job moves, she got married organising the wedding completely by herself within a short space of time. This added to her stress levels although she appeared to cope well with all the additional planning necessary. She has a very busy life both socially and professionally. She rates her stress levels as low work 4/10 and home 2/10 and she has a positive, pro-active approach to life. Mrs MB is a keen amateur triathlete who had a regular training schedule. However, before her last event she developed severe back pain that resulted in a visit to a physiotherapist. She had to withdraw from her last two races, a triathlon and half-marathon and has now stopped her training programme completely. She did not visit her doctor, but the physiotherapist recommended remedial exercises that have helped. She has recently started to exercise again, swimming once a week and cycling occasionally but not at the same level as previously practised. She suffers no contraindications and is generally in very good health. She eats a healthy diet, mostly organic and is a non-smoker. She does suffer with occasional eczema on her hands and her skin is slightly dry but she feels that this is age related. Mrs MB feels that her back problems may be due to over training, particularly increased running and the change in her office environment. She thinks that massage may help to improve her circulation and relax her back muscles and prevent aches and pains. She has signed an informed consent form, and has been made fully aware of the treatment and its effects. Reason for treatment Intermittent back ache/pain/stiffness back pain started in August due to an increased running programme and a change in work/office environment. It has now eased but Mrs MB is anxious that it may return. Treatment Plan A full body massage once a week for four weeks is proposed using the full range of classical massage movements with particular emphasis on the lower back/problem area to help prevent muscle stiffness. Treatment 1-05/11 The room was a little cold so additional heating was necessary to ensure client comfort. A full body massage was performed, with extra work/emphasis on the lower back, lumbar, sacral and gluteal regions. The massage medium chosen was grapeseed oil which is light and easily absorbed. Although the client does not suffer a nut allergy, she has a strong dislike of nuts and nut products so I felt it unwise to use sweet almond oil. It was necessary to adjust the pressure used on the back as the client was quite sensitive experiencing mild discomfort during petrissage on the sacral area. I used a lighter pressure for these movements that the client could tolerate. Mrs MB had come straight from work so she was very alert. She had experienced massage before so was not apprehensive about the treatment. However, as this was her first treatment with a different therapist, she talked throughout the treatment and was very interested in the different techniques experienced. No

4 additional support was required by the client. Some discomfort was felt in the sacral area, so pressure was applied within the client s tolerance to help with relaxation. She felt relaxed and refreshed after the treatment, not sleepy and said that her back felt looser. I sat Mrs MB up slowly and she was given a glass of water immediately after the massage to help flush out any accumulated toxins. She was advised to increase her water intake as she currently drinks no water in addition to her daily coffee, herbal tea and fruit juice. She could also try to cut down on her caffeine intake. She was given exercises to perform by her physiotherapist to improve the flexibility in her back so it is important that she continues with these daily. She was also advised to go home and relax for the rest of the evening if possible. Reflective practice At the end of the first treatment I felt pleased with the outcome. I did feel that Mrs MB would have benefited from the treatment more if she had remained quiet throughout rather than talking, but this seems to be quite common for clients during their first few sessions. It is important to build a rapport with the client and many find it stress-relieving. It is also a good way of noting things that they might have forgotten to mention during the consultation. I need to work out a way to ask clients to be quiet in a polite way! Treatment 2-12/11 Although Mrs MB felt looser after the last massage, the back stiffness returned quite quickly within the next day. However, she felt that she slept better after the treatment. There have been no changes to Mrs MB s overall health this week. A full body massage was performed, again with emphasis on the lower back/sacral area, using a full range of massage movements. Although Mrs MB stated that she had cellulite on her legs during the initial consultation, I found that her legs were very well toned. As a result I needed to apply more pressure in order to work the tissues adequately, particularly with the wringing and finger rolling movements. The skin did feel quite cold to the touch in these areas though, perhaps indicating poor circulation. Mrs MB arrived straight from work feeling slightly harassed. She then announced that she was on a tight deadline and had to leave in just over one hour. She appeared quite tense throughout the massage and it was obvious that her mind was buzzing with thoughts of the rest of the evening. Whilst she may have experienced some of the physical benefits of massage, such as increased circulation, I was sure that the psychological effects this evening were poor as she seemed quite alert throughout the treatment. She experienced less discomfort this week in the lumbar/sacral area, so I was able to apply a little more pressure and work for longer. I still avoided the use of the tapotment movements on the gluteal region. I sat her up slowly, even though she needed to get going quickly. She said that she felt relaxed and comfortable but after her glass of water, she dressed and left quickly. Mrs MB was again advised to increase her water intake. She has been trying this week but kept forgetting. I suggested that she keep a bottle of water on her desk or have a glass of water each time she has a cup of coffee. She is continuing with the physiotherapist recommended exercises. The next treatment will be in one week. Reflective practice I felt I rushed through the routine and I forgot some movements. I performed the massage too quickly as I was conscious throughout of the client s time limits. I completed the whole routine in approximately 50 minutes rather than just over an hour. She did not relax fully but appeared to enjoy the treatment nevertheless. I felt disappointed that I let the client s mood affect my performance and I need to be conscious of this for each client

5 Treatment 3-19/11 Mrs MB has had a very busy week, frequently staying at work much later than planned. Again she seems quite tense, but is looking forward to the treatment. Her lower back stiffness eased slightly this week but because she has been busy, she has only managed one of her recommended exercises each day. She thinks the stiffness is due to increased time at her desk, looking at a computer. However, she has altered her desk layout to prevent back strain/stretching incorrectly to reach files etc. She feels more relaxed mentally. Full body massage utilising complete range of massage movements. Client experienced discomfort/stiffness in right shoulder and upper trapezius right hand side, so light petrissage movements were performed, checking the client s tolerance. Her skin absorbed the oil well. Hyperaemia was evident particularly on the edge of the scapula/rhomboid region right hand side. I was able to work over the lumbar/sacral area more fully this week without Mrs MB experiencing any discomfort. She felt a little tense and tired due to her increased workload but was looking forward to relaxing. She was not really conscious of the tension in her upper back muscles until I worked over them (rhomboids, trapezius), when they became quite painful to touch. Her forearms were also tense and tender when I performed petrissage movements draining to the supratrochlear lymph nodes. She has spent many hours this week inputting data on her computer, sitting in the same position for a long time. She was very quiet this week and appeared to relax fully. She felt completely relaxed at the end of the treatment. A glass of water was given to Mrs MB immediately after treatment. She has managed to increase her water intake this week and will try to maintain it this week. However, her busy week has meant that she has not performed as many of her exercises, only managing one every morning. She is keen to start her training regime again shortly so we discussed the importance of warming up and cooling down exercises. She admits that whilst she is aware of the correct techniques, she does not always use them fully. She is pleased with the effects of regular massage and will continue with it and increasing her back exercises to maintain and improve flexibility. Her new desk layout should also help ease her back strain, as she now has everything within easy reach. Decaffeinated coffee is now available in her office and she is trying to alternate it with normal coffee to cut down her caffeine intake. Reflective practice I felt more confident with the routine this evening. It also helped that tonight Mrs MB seemed more relaxed from the start. She did not chat to me so I was able to concentrate fully and felt that the massage was more beneficial as a result. Last week the treatment outcome was affected as Mrs MB was unable to relax afterwards. The immediate effects of the treatment were short lived as she was forced rush to another appointment immediately after. Treatment scheduling is important as relaxation time after a session is advisable. Treatment 4-26/11 Mrs MB arrived for her treatment in a cheerful and relaxed manner. Her workload is still higher than normal but at the weekend she completed a long bicycle ride with no ill effects afterwards. Although she is currently working longer hours she feels calm and able to cope with the demands of her job. Her back stiffness seems to be easing and her workspace reorganisation seems to be making things easier as she is no longer stretching awkwardly to reach files and documentation that she needs. Full body massage using complete range of massage movements. Frictions used on the rhomboids and trapezius, again erythema evident particularly on the right hand side. However, this was not as uncomfortable as last week and her shoulder feels less stiff. Knots in the rhomboid area were not as firm this week but petrissage was used to improve the circulation, break down fibrous build up and eliminate lactic acid from tension. The lumbar/sacral area was less tense, although some of this tension appears to have transferred to the upper back but I can now work this area fully without discomfort to the client. Although her work-load has increased due to the time of year, she feels happy and able to cope in her new job. Has found weekly treatments very beneficial and they have encouraged her to make some other simple

6 changes which are helping with back tension. The back massage was more comfortable this week, and the trapezius/shoulder area less painful. This seems to be more of a problem than the lower back now, but may ease as her workload normalises shortly. Care was still taken during the back massage with regard to sensitive areas but Mrs MB fully receptive to all massage movements performed firmly on the rest of the body. She feels that the effects of the treatment have been cumulative and she feels relaxed for longer between sessions. Mrs MB was given a glass of water immediately after the treatment. She is continuing to drink more water and reduce her caffeine intake she has graduated onto fully decaffeinated this week. If she is starting to increase her exercise levels and feels stiff as a result she could take a warm bath in the evenings to relax the muscles before bed. She must also ensure that she warms up/cools down before and after exercise as she begins to build up her fitness levels again. Massage treatments are recommended at least once per month or as required as a preventative measure and to continue relaxation. She should also continue to perform the exercises recommended by her physiotherapist as they seem to be helping prevent stiffness, even though she is only managing to perform a limited amount daily. Reflective Practice It was very interesting to observe the effects of an increased workload/change in work patterns on her posture/muscles. This had a direct effect on my massage routine and the emphasis in a treatment. I was able to identify tight muscles/problem areas even though she did not necessarily point them out to me. I then adjusted my treatment and spent more time working on these areas to release the tension and increase the blood flow. It was also a good experience working on a client with specific needs i.e., relief from pain/muscular tension. It was much easier to note improvements than if working on someone who just wants general relaxation. The pain/discomfort here could be used as a guide to treatment effectiveness/success. It was interesting to see how the client s mood affected my treatments particularly in terms of speed. When the client was stressed and anxious about time, I allowed myself to be influenced instead of focussing on making the client relax through a deep and slow massage. It was helpful to work with someone who was clearly interested in helping herself regain fitness, flexibility and prevent further pain or injury. I look forward to continuing to work with this client throughout her return to fitness and forthcoming competitions. Overall conclusion Mrs MB has benefited from weekly massages, coping with a heavy workload and using the treatment sessions to unwind. She has become more aware of her posture and has changed her desk around to prevent further damage and feels that this is helping. She is more alert during the day and feels that drinking more water has helped. She will continue to drink decaffeinated coffee at work. Mrs MB is fit and body aware, but she must be careful not to over exert herself as she tries to regain her fitness levels. She has found that the massages have made her more aware of how she is feeling physically and hopes that this will guide and help her not to overdo her training when she starts properly. Not all clients undertake home/aftercare advice. It was very interesting to see how improvements in health could be made when the client takes advice and makes changes.