Massage Therapy Initial Evaluation (SOAP)

Client Name: [Client full name]

Date of Birth: [DOB]

Date of Service: [Date]

Session Time: [Start time – End time (total minutes)]

Location/Setting: [clinic / mobile / home / other]

Therapist: [Therapist name, credentials, license #]

Source of History: [client / guardian / caregiver / referral / interpreter-assisted]

Subjective

Chief Concern: "[Primary reason for visit in client's own words]" (Use a direct quote when possible)

Secondary Concerns: [Other concerns, if any] (Include only if stated)

History of Present Condition: [Chronological summary of onset and course, location/distribution, quality and severity pattern, aggravating and alleviating factors, associated safety symptoms (numbness, tingling, weakness, swelling), and relevant prior care or diagnostics as reported] (Write 3–6 sentences flowing chronologically; for wellness/relaxation visits, abbreviate or omit)

Pain and Symptom Baseline:

• [Current pain rating (0–10)]
• [Best and worst ratings with timeframe]
• [Other relevant baseline symptoms (stiffness duration, sleep disturbance, morning soreness)]

(Omit section if no pain or symptoms reported)

Functional Impact: [Specific activities limited and how—work tolerance, sleep quality, exercise capacity, ADLs] (Provide concrete examples)

Client Goals and Preferences:

• [Therapeutic goals: pain reduction / improved mobility / stress relief / relaxation / other]
• [Pressure preferences: light / moderate / deep / variable]
• [Areas to focus and areas to avoid]
• [Sensitivities, boundaries, or other considerations]

Relevant Health History:

• [Significant medical conditions relevant to massage (cardiac history, clotting disorders, cancer history, neuropathy, osteoporosis, diabetes)]
• [Recent surgeries or acute injuries with approximate dates]
• [Skin integrity concerns]
• [Pregnancy status] (if relevant)
• [Implants or medical devices]
• [Medications relevant to safety: anticoagulants / steroids / analgesics / other]
• [Allergies or sensitivities: topicals / latex / fragrances / other]

Contraindication and Red-Flag Screening: [Items screened, findings, and clinical action taken: treated as planned / modified / deferred / referred] (Screen for: fever or acute infection, suspected DVT or unexplained limb swelling, uncontrolled hypertension or unstable cardiac symptoms, contagious skin conditions, recent surgery or trauma, neurologic red flags such as progressive weakness or bowel/bladder changes)

Consent: [Consent to treat: obtained / declined / deferred]; [Draping: standard / modified per client request] (Note any modifications to treatment boundaries)

Objective

General Observations: [Apparent distress or guarding, ease of movement, posture, gait, visible skin findings relevant to care]

Palpation and Tissue Assessment: (Organize by region with L/R designation; distinguish therapist findings from client-reported tenderness during palpation)

• [Region]: [Tissue tone, taut bands, trigger points, myofascial restrictions, temperature differences, edema, texture changes]; Client-reported tenderness: [location and severity]
• [Additional regions as applicable]

Objective Measurements: (Include if performed)

• [ROM: region, active/passive, measurement, method (visual estimate / goniometer)]
• [Functional tests within scope: test name, result, side]
• [Pain provocation: movement tested, symptom reproduction and location]

Safety-Relevant Findings: [Unexplained swelling, marked warmth/redness, severe pain with light touch, widespread bruising, concerning rash, and immediate action taken] (Omit if none identified)

Assessment

Summary: [1–3 sentence synthesis connecting subjective history, objective findings, and client goals using scope-appropriate terms (tissue hypertonicity, myofascial restriction, tender trigger points, guarding, limited ROM)] (Attribute any diagnoses as "client-reported" or "per referral")

Problem List:

• [Primary problem]
• [Secondary problem]
• [Additional problems as applicable]

Contributing Factors: [Postural patterns, occupational demands, activity load, stress, sleep, ergonomics]

Safety Decision: [treated as planned / modified technique or areas / deferred treatment / referred out] (Include brief rationale for any modification, deferral, or referral)

Prognosis: [Expected response trajectory and factors that may affect progress] (Optional)

Plan

Treatment Today: (If no treatment performed, state reason and what was done instead)

• Areas treated: [Target regions with laterality]
• Positioning: [prone / supine / sidelying / seated / mixed]
• Techniques: [effleurage / petrissage / myofascial release / trigger point therapy / compression / friction / stretching / other]
• Pressure: [light / moderate / deep]; Tolerance: [client feedback]
• Topicals: [Products used and any sensitivities accommodated]
• Response: [Client response during and immediately after—pain or mobility changes, relaxation response, any adverse responses]

Home Care:

• [Stretches or mobility exercises with frequency and duration]
• [Self-massage or heat/cold guidance]
• [Ergonomic or activity-modification suggestions]
• [Red-flag symptoms requiring urgent medical evaluation]

Recommended Frequency: [Visit frequency (e.g., 1–2x/week initially)] for [duration before reassessment (e.g., 4–6 visits)] (Tie rationale to severity and goals; note tapering plan if applicable)

Goals: (2–4 measurable goals with metrics and timeframes)

• [Goal 1 with metric and timeframe]
• [Goal 2 with metric and timeframe]
• [Goal 3 with metric and timeframe]

Reassessment Interval: [Timeframe]

Referrals/Coordination: [Referral to whom, reason, and whether ROI is on file] (Omit if not applicable)

Therapist Signature: [Signature]

Date/Time Signed: [Date and time]

Printed Name and Credentials: [Name, credentials, license #]