Client records at a massage centre: assessment, consent, history
What to fill in on the first visit, which health questions really matter, why consent is written down and what to note after every session.
At a massage and wellness centre, the client record solves two completely different problems. The first is safety: there are conditions where a certain pressure or area shouldn’t be worked on. The second is continuity: the second session should start where the first one finished, not from scratch.
To be clear from the outset: we’re talking about wellness and relaxation services here, not clinical practice. You don’t diagnose and you don’t replace a doctor — which is exactly why the record must show where you stop and when you refer.
The first visit: what’s filled in before the couch
- Contact details and mobile number — reminders are tied to it.
- What brings the client in: tension in the shoulders, desk work, sleep, relaxation, recovery after exercise.
- Health conditions that change the session (see below).
- Medication that matters — anticoagulants, steroids, drugs that affect blood pressure.
- Recent injuries, operations or fractures, with dates.
- Preferences: pressure, areas they don’t want touched, oils and scents, temperature, music, conversation or silence.
That last line is what makes the difference to the experience. A client who never has to repeat that they don’t like lavender and would rather you avoid the abdomen already has a reason to come back.
The health questions that matter
A three-page questionnaire doesn’t get filled in or read. You need the few questions that genuinely change what you’ll do:
- Pregnancy or recent childbirth.
- Cardiovascular conditions, high blood pressure, thrombosis or a history of it.
- Skin conditions, open wounds, burns, infections.
- Osteoporosis, disc problems, recent fractures, metal implants.
- Diabetes and neuropathy — they change how pressure is felt.
- A history of cancer or ongoing treatment.
- Fever or acute inflammation today.
- Allergies to oils, waxes, fragrances.
Next to every “yes” you need one line: what else you asked and what you changed in the session. That line is your professional judgement on record, and it’s the only thing that shows you didn’t skip over it.
When not to go ahead with the session
The hardest rule at a wellness centre is “not today”. Fever, acute inflammation, unexplained severe pain, a suspicious skin finding, a condition the client hasn’t shown a doctor: the right move is postponement and referral, not a gentler session.
Write it on the record when it happens. The client will remember it as care, not as a refusal — and you’ll have the record should you ever need it.
Consent: in writing, once, and renewed
The consent form isn’t a legal trick; it’s the written version of the conversation you’re already having. It covers four things:
- What the service is and what it isn’t — a wellness service, not a medical procedure or diagnosis.
- That the client has declared their health conditions and will let you know if anything changes.
- That they can ask for a change of pressure or for you to stop at any time.
- How their data is kept and how it’s deleted if they ask.
It’s renewed when something significant changes and, as a matter of practice, once a year for regular clients — because the health history from 2024 isn’t today’s.
After every session: four lines
- What you worked on — areas, technique, duration.
- Pressure and how the client tolerated it.
- What you found and what they reported: where they were tense, what eased, what didn’t.
- What you’re planning next time and after how long.
Two minutes while the client gets dressed. Nothing gets written in the evening, and after three clients nobody remembers who had what.
Health data needs a little extra care
Anything you write about a client’s health is a special category of personal data. Three things are enough in practice: keep only what you use, the record isn’t visible at reception or on a shared computer, and there’s a way to delete a record when asked.
In PhysioPro, the client’s record, session history, notes and appointments are on one screen, with the health history at the top — so “what did we say last time?” is answered before the session starts.
Conclusion
A few questions that genuinely change the session, one line for every “yes”, written consent that’s renewed, and four lines after every visit. That’s all — and it’s the difference between a massage and a relationship that lasts for years.