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MASSAGE THERAPY S.O.A.P. NOTE
Client Name: _______________________________________________ Date: _______________________
SUBJECTIVE: (Client presents with and complains of):
q Sharp Pain q Dull Ache q Numbness q Tingling q Burning q Shooting q Throbbing
Other / Notes:
__________________________________________________________________________________
______________________________________________________________________________________________
v These complaints are noted in the client’s:
q
Neck q Shoulders q Upper Arms q Lower Arms q Upper Back q Sides q Chest
q
Abdomen q Groin q Lower Back q Buttocks q Upper Legs q Lower Legs
Other / Notes: __________________________________________________________________________________
______________________________________________________________________________________________
OBJECTIVE: (Found during the course of evaluation and treatment):
q
Pain q Tenderness q Muscle Spasm q Trigger Points q i
/
h Muscle Tone q i
/
h ROM
q i
/
h Muscle Texture Other / Notes: ___________________________________________________
______________________________________________________________________________________________
v These findings are noted in the client’s:
q
Neck q Shoulders q Upper Arms q Lower Arms q Upper Back q Sides q Chest
q
Abdomen q Groin q Lower Back q Buttocks q Upper Legs q Lower Legs
Other / Notes: ___________________________________________________________________________________
______________________________________________________________________________________________
ASSESSMENT: (Your opinion of the client’s condition):
q
Muscle Spasm q Neck Pain q Thoracic Pain q Lumbar Pain q Arm Pain q Leg Pain q Chest Pain
Other / Notes: ___________________________________________________________________________________
______________________________________________________________________________________________
The client is: q Improving q Staying the Same q Getting Worse q N/A – First Visit
Client prognosis is: q Excellent q Very Good q Average q Poor q Dire q Too soon to ascertain
PROCEDURE / PLAN: (What was done and what is the future plan):
q
60 min. massage (97124) - 4 units q 30 min. massage (97124) - 2 units
q Return in _______ weeks q Chiropractic Referral q Recommend Icing q Recommend stretching
q Increase Water Intake Other / Notes: ______________________________________________________________
More or Less Pressure Next Massage: ____________________________________________________________________
Next Massage, Concentrate On: _______________________________________________________________________
Therapist’s Signature: ________________________________________ Date: _______________________
Supervising Doctor’s Signature: ________________________________ Date: _______________________
BUSINESS NAME
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