Free Massage Therapy Soap Note

Prepared by: [Your Name]

I.Subjective

• Client's Reported Symptoms: The client reports experiencing moderate tension in the lower back and shoulders. The client mentions feeling increased stress due to work and has been experiencing difficulty sleeping.

• Pain Level: The client rates pain as a 6/10 in the lower back and a 5/10 in the shoulders.

• Previous Treatments: The client has received occasional massage therapy in the past with positive results. No other treatments are being pursued currently.

II. Objective

1. Observations:

   • Posture: The client exhibits mild forward head posture and rounded shoulders.

   • Muscle Tension: Noticeable tension in the trapezius and lower back muscles.

   • Range of Motion: Limited shoulder range of motion with discomfort reported during shoulder abduction.

2. Palpation Findings: Tenderness and tightness in the thoracic and lumbar regions.

3. Skin Condition: No visible signs of irritation or inflammation.

III. Assessment

• Therapist's Evaluation: The client appears to be dealing with muscle tightness and postural imbalances likely caused by prolonged sitting and stress. This could be contributing to the reported discomfort and pain in the lower back and shoulders. The range of motion limitation suggests possible soft tissue restrictions in the shoulder area.

IV. Plan

1. Treatment Goals:

   • Reduce muscle tension and improve mobility in the shoulders and lower back.

   • Enhance relaxation and stress relief.

2. Planned Treatment:

   • Focus on deep tissue techniques for the shoulders and lower back to release tight muscles.

   • Use stretching and range-of-motion exercises for the shoulder to improve flexibility.

   • Recommend regular stretching and self-care techniques to manage stress and prevent muscle tightness.

3. Frequency of Sessions: Schedule follow-up sessions once a week for the next month, adjusting as needed based on the client's progress.

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