Assessment and Evaluation on Comprehensive Health Assessment

Prepared by: Manny P. Daleon-Massage Therapist

I.

Patients Profile:
Name:_______________________________
Age:____________________________
Date of Birth:_________________________
Gender:_________________________
Place
of
Birth:_________________________
Address:_________________________
Occupation:___________________________ Contact
No:_______________________
Spouse:______________________________
Handedness:______________________
Contact No:___________________________ Any
Allergies:_____________________

In Case of Emergency:
Contact Person:____________________________
Contact
Number:__________________
Purpose
of
Visit:______________________________________________________________

II.

Subjective:
1. Information from Client:
Medicines Taken:
i. __________________________________________________________
____
ii. __________________________________________________________
____
iii. __________________________________________________________
____
Q. What part of your body you dont want to be touched?
__________________
2. Clients Subjective Complain & Symptoms
a. Onset of Symptoms:__________________________________________
b. Pain?______________________________________________________
c. Pain
Scale?(110)_____________________________________________
d. Stress?
_____________________________________________________
e. Limitations of Activities of Daily Life:(A-D-E-P-T)
Ambulation(Can he walk or not?)
Dressing(Can he dressed alone?)
Eating
Personal Hygiene
Toilet Transfers(Can he go alone?)
3. Past Medical History & Family History:
Family History:(Parents History of Diseases)
Fathers Side:

1. _____________________________________________________________
_
2. _____________________________________________________________
_
3. _____________________________________________________________
_
4. _____________________________________________________________
_
5. _____________________________________________________________
_
Mothers Side:
1) _____________________________________________________________
_
2) _____________________________________________________________
_
3) _____________________________________________________________
_
4) _____________________________________________________________
_
5) _____________________________________________________________
_
Past Medical History:
Are you Diabetic?
_________Yes
___________No
Are you hypertensive?
_________Yes
___________No
Are you Arthritic?
_________Yes
___________No
Are you hospitalized _________Yes
___________No
Patients Present Condition
Chief
Complain_________________________________________________________
__
(Please relate when does the pain started?)
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________

III.

Objective:
Vital Signs:
Pulse:___________________
Heart Beat:__________________
Blood Pressure:___________
Temperature:________________
Range of Motion Exercise:
Was there a limitation of movements?
_____Yes
_____No

IV.

Plan:
1. Treatment:
Swedish Massage
Reflexology
Acupressure

2. Duration:
3 x a week
2 x a week
Once a week
3. Clients Instructions:
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________

___________________________
_________________________
Clients Signature

Massage Therapist NC II