Massage Treatment Record & Client Feedback Form

1.Client Information

First name

Last name

Birthday

Month

Day

Year

Occupation

2. Pain Level Assessment

Please rate your pain or discomfort before and after this massage session.

(0 = No pain, 10 = Most severe)

***Please answer only for the body areas treated during this message session.

Body Area Before Treatment After Treatment

Neck Before Treatment 0=No pain, 10 = Most severe

Neck After Treatment 0=No pain, 10 = Most severe

Shoulders Before Treatment 0=No pain, 10 = Most severe

Shoulders After Treatment 0=No pain, 10 = Most severe

Arm - Left Before Treatment 0=No pain, 10 = Most severe

Arm - Right After Treatment 0=No pain, 10 = Most severe

Elbow - Left Before Treatment 0=No pain, 10 = Most severe

Elbow - Right After Treatment 0=No pain, 10 = Most severe

Wrist /Hand - Left Before Treatment 0=No pain, 10 = Most severe

Wrist /Hand - Right After Treatment 0=No pain, 10 = Most severe

Upper Back Before Treatment 0=No pain, 10 = Most severe

Upper Back After Treatment 0=No pain, 10 = Most severe

Lower Back Before Treatment 0=No pain, 10 = Most severe

Lower Back After Treatment 0=No pain, 10 = Most severe

Hips Before Treatment 0=No pain, 10 = Most severe

Hips After Treatment 0=No pain, 10 = Most severe

Legs Before Treatment 0=No pain, 10 = Most severe

Legs After Treatment 0=No pain, 10 = Most severe

Knee - Left Before Treatment 0=No pain, 10 = Most severe

Knee - Right After Treatment 0=No pain, 10 = Most severe

Ankle/Foot - Left Before Treatment 0=No pain, 10 = Most severe

Ankle/Foot - Right After Treatment 0=No pain, 10 = Most severe

3. Post-Treatment Effect

Please tick the option that best describes how you feel after the massage:

Significant improvement/ดีขึ้นอย่างมาก

Slight improvement/ดีขึ้นเล็กน้อย

No change/ไม่เปลี่ยนแปลง

Worse than before/ แย่ลงก็ว่าเดิม

Other _________________

4. Satisfaction Rating /การประเมินความพึงพอใจ

Please rate your experience today (1 = Poor, 5 = Excellent)

Therapist’s understanding of your issue / ความเข้าใจของนักบำบัดต่อปัญหาของคุณ

5. Additional Comments (Optional): / ความคิดเห็นอื่น ๆ (ไม่บังคับ)

Date picker

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