Condition Assessment Form

During the first visit, a condition assessment is carried out based on the following assessment form. This is a 10–15 minute process, which is essential for accurately and effectively planning the treatment and thus achieving the desired outcome.

Basic Information

Name:
Address (for invoicing):
Phone number:
Email address:

Complaint Analysis:

Do you suffer from chronic pain? YES / NO

When did the pain begin? ________________________________________________

Can you identify a triggering factor? _______________________________________

In your opinion, what causes the pain (illnesses)? _____________________________

What relieves the pain? _________________________________________________

What worsens or increases the pain? _______________________________________

How would you describe the intensity of the pain:
dull / sharp / stabbing-sharp / cramping / numb / tingling / pressing / throbbing / radiating – to where: _______________________________________________

Does it worsen with movement? YES / NO
Does it worsen at night? YES / NO

Have you had orthopedic surgery? YES / NO
If yes, please describe: _________________________________________________

General Contraindications:
Tumor | Untreated blood pressure problems | Advanced osteoporosis | Sprain, dislocation (within 6 weeks) | Muscle or ligament rupture (within 8 weeks) | Acute inflammation | Infectious diseases | Fever | Recent trauma (e.g., fracture), post-surgical recovery period | Untreated heart problems | Ulcer | Deep vein thrombosis | Bleeding disorders | Pregnancy 1st and 3rd trimester | Varicosity, superficial vein inflammation in the affected area | Skin infection, dermatitis | Joint inflammation, swelling in the region

Do any of these apply to you?

Additional Conditions:
Headache / Migraine | Numbness | Joint problems | Sedentary work | Physical labor | Inactive lifestyle | Unhealthy lifestyle (e.g., smoking) | Low fluid intake | Varicose veins | Arthritis | Fibromyalgia

Massage Information:
Have you ever had massage therapy before? YES / NO

Preferred pressure: Gentle / Medium / Strong

Do you have any allergies or sensitivities? YES / NO
If yes, to what? ________________________________________________

Preferred medium: Cream / Oil / No preference

Is there any area you do not want to be treated? If yes, please specify: ___________

Mark the area where you feel the most intense pain: __________________________

Do you have scoliosis (spinal curvature)? _________________________________

Therapist's Notes:

Suspected cause of symptoms: Stress / Physical strain / Inflammation / Degeneration

Observation:
Functional impairment (any movement limitations?): ___________________________

Posture – muscle tension:

• body proportions:

• contours (muscles, bones, joints):

• physiological curves of the spine: alterations in cervical / thoracic / lumbar / sacral region – position of pelvis and shoulders:

• skin condition: pallor / hyperemia / pigmentation / sebaceous activity / dryness / scars / temperature differences

Palpation Assessment:
Location of muscle tension: _____________________________________________
Estimated level of resolvability: easily / moderately / difficult to release
Knots, triggers, adhesions: _____________________________________________

Proposed Treatment Plan:
Number of sessions: _____________
Frequency: ____________________
Primary treatment areas: ______________________________________________
Massage techniques to be applied: _______________________________________
Tools to be used: _____________________________________________________

Data Protection Notice:
Your personal and health-related information is processed solely by me.

Date:
Client's signature: _______________________