Massage SOAP Notes
Date of Service
Client First / Last Name
Email Address
Referral, Who and Why
Subjective
Symptom Analysis
Select all
Clear choices
Adhesions
Hypertonicity (rigid)
Inflammation
Pain
Spasms
Trigger Points
Tender Joints
Area with the highest level of pain or discomfort
Arms
Back
Feet
Hands
Hips
Inflammation
Legs
Neck
Shoulders
Trigger Points
Upper Chest (pec area)
Additional areas of pain and discomfort
Select all
Clear choices
Arms
Back
Feet
Hands
Hips
Inflammation
Legs
Neck
Shoulders
Trigger Points
Upper Chest
Client Goals
Additional Notes
Level of Life Stress
Low
Medium
High
Pre-Massage Overall Level of Pain and Discomfort on a scale of 1-10 (10 being the highest)
1
2
3
4
5
6
7
8
9
10
Specific areas of pain and discomfort
Ankle - Left
Ankle - Right
Arm - Left
Arm - Right
Back
Finger(s) - Left
Finger(s) - Right
Foot - Left
Foot - Right
Hands
Hip - Left side
Hip - Right side
Joints
Knee - Left
Knee - Right
Leg - Left
Leg - Right
Neck- Left
Neck - Right
Ribs - Left
Ribs- Right
Shoulder - Left
Shoulder - Right
Additional Notes
Objective
Therapies
Deep Tissue
Swedish
Neuromuscular
Cranial Sacrel
Therapeutic
Sports
Prenatal
Reflexology
Trigger Point Therapy
Effleurage
Petrissage
Friction
Kneeding
Tapping
Tuning Fork
Treatment
Face muscles
Select all
Clear choices
Buccinator, a thin muscle in the cheek that holds each cheek toward the teeth
Lateral pterygoid, a fan-shaped muscle that helps the jaw open.
Masseter, a muscle that runs from each cheek to each side of the jaw and helps the jaw close.
Medial pterygoid, a thick muscle that helps the jaw close
Temporalis, a fan-shaped muscle that helps the jaw close
Zygomaticus major and minor, which allow a smile
Treatment
The suboccipital muscles are a group of four muscles situated underneath the occipital bone.
Select all
Clear choices
Rectus Capitis Posterior Major - Extension and rotation of the head
Rectus Capitis Posterior Minor - Extension of the head, most medial of the suboccipital muscles. There is a connective tissue bridge between this muscle and the dura mater (outer membrane of the meninges)
Obliquus Capitis Inferior - Extension of the head, Originates from the spinous process of the C2 vertebra and attaches onto the transverse process of C1
Obliquus Capitis Superior - Extension of the head, located laterally in the suboccipital compartment
Treatment
Neck muscles
Select all
Clear choices
Platysma - helps jaw/mouth movements
SCM - helps move the head, extend neck, control temporomandibular joint
Subclavius -Stabilizes your collarbone when moving shoulder and arm
Suprahyoids - 4 muscles that move the hyoid bone when swallow and speak
Infrahyoids - 4 muscles below your hyoid bone that move larynx (voice box) up and down.
Scalenes - Three muscles that move your first two ribs up and down so you can inhale air when you breathe, stabilize cervical vertebrae and moves head
Treatment
Shoulder muscles
Select all
Clear choices
Subscapularis - This muscle attaches to the middle part of your scapula and stretches to the bottom part of the ball of your humerus
Supraspinatus - stretches from the top of the scapula to the top of the humerus, at the ball of your shoulder joint
Infraspinatus - stretches from the bottom of the scapula and connects to the humerus behind the supraspinatus
Teres minor - attaches to the side of the scapula and attaches to the humerus beneath the infraspinatus
Treatment
Muscles that support the shoulder
Select all
Clear choices
Rhomboids - stretch from the top of your spine (at the base of your neck) to your scapula. They help you lift your shoulder blad
Trapeziu - s - a large triangular muscle at the back of your shoulder. It helps you lift and lower your shoulder.
Deltoid - is on the outside of your shoulder. It helps you move your arm forward, backward and to the side.
Treatment
Back muscles
Select all
Clear choices
Latissimus dorsi - helps extend and rotate the shoulder and arm
Levator scapulae- raises your scapula (shoulder blade)
Rhomboids - two muscles (the rhomboid major and minor) that work together to pull the scapula inward toward the spine
Trapezius (traps), which helps move the body, raise arms and have good posture.
Treatment
Chest muslces
Select all
Clear choices
Pectoralis Major - Adducts and medially rotates the upper limb and draws the scapula anteroinferiorly.
Pectoralis Minor - Stabilises the scapula by drawing it anteroinferiorly against the thoracic wall.
Serratus Anterior - Rotates the scapula, allowing the arm to be raised over 90 degrees. It also protracts the scapula, holding it against the ribcage.
Subclavius - Anchors and depresses the clavicle
Treatment
Arm muscles
Select all
Clear choices
Biceps - in the middle of your upper arm
Brachialis- deep muscle sits underneath the biceps
Coracobrachialis - deep under your biceps, this muscle connects to the scapula (shoulder blade).
Triceps brachii - on the back of the arm, just above the elbow
Treatment
Hip muslces
Select all
Clear choices
Include the gluteals, adductor muscles, iliopsoas muscle, quadriceps and hamstrings.
Treatment
Leg muscles
Select all
Clear choices
Quadriceps femoris (quads), which actually includes four muscles that start in the upper leg and end at the knee
Hamstring
IT Band
Treatment
Calf muscles
Select all
Clear choices
Gastrocnemius - is just under your skin at the back of your lower leg
Soleus - is wide and flat and sits slightly deeper than the gastrocnemius muscle. It starts just below the knee, runs down the lower leg and connects to the Achilles tendon above your heel.
Plantaris - runs between your gastrocnemius and soleus down the length of the lower leg
Treatment
Foot ligaments
Select all
Clear choices
Plantar fascia- Runs underneath your foot from the heel to the base of your toes.
Calcaneocuboid ligament: Connects your heel bone to your tarsal bones that make up your foot’s arch.
Objective Assessment
Visual Postural Analysis
Limps
Muscle guarding
Holding patterns
Movement inconsistency
Atrophy
Hypertrophy
Bruises
Abrasions
Scars
Swelling
Redness
Skin irregularities
Varicose veins
Irregular breathing patterns
Assessment
Overall Post-Massage Level of Pain and Discomfort on a scale of 1-10 (10 being the highest)
1
2
3
4
5
6
7
8
9
10
Post Massage Result
Better Movement
Better Posture
Better Range of Motion
Better Sense of Well Being
Better Sleep
Feel Lighter
Feel Taller
Higher Levels of Energy and Vitality
Less Pain
Less Stiffness
Less Tension
More Flexibility
Reduced Inflammation
Reduced Stress
Relaxation
Plan
Come Back
1 x week for 2 weeks
1 x week for 3 weeks
1 x week for 4 weeks
2 x week for 2 weeks
2 x week for 4 weeks
Monthly
Quarterly
Other:
Explain Other:
Home Care
Elevation
Exercise
Heat
Ice
Ice/Heat
Nature
Nutrition
Stretching
Rest
Water Intake
Additional Comments
Therapist Signature
Clear
Date
MM
/
DD
/
YYYY
Verification
SUBMIT FORM
Please wait...
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20