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 : ____________________________________________________________________________
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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 : _______________________________________________________________________
_____________________________________________________________________________________________________________________
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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 ______________
