Massage Therapy Licensing Exam (MBLEx) · Client Assessment, Reassessment & Treatment Planning
Massage Therapy Licensing Exam (MBLEx): Client Intake and Assessment Concepts
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Overview
This chapter covers how you gather information before you start working. Good assessment keeps the client safe and helps you choose the right approach. The exam asks about the intake form, the interview, what you observe, and how to record it.
The process starts with a health history form and a short interview. You ask about the reason for the visit, past injuries, current conditions, and medications. The form should be updated at each visit, because health can change between sessions.
Next comes observation and testing. You may look at posture, watch the client walk, and gently feel the tissue. Range of motion tests show how far a joint can move. Active range of motion is done by the client alone, while passive range of motion is when the therapist moves the relaxed limb.
Findings are often written in SOAP notes. Subjective is what the client tells you, Objective is what you see or measure, Assessment is your summary of what changed or what you found, and Plan is what you will do next. Clear notes help you track progress over time.
Key concepts
Health history (intake form)
A written form the client fills out before the first session, listing health conditions, injuries, medications, and goals. It helps find contraindications.
Memory tipNo massage before the history is reviewed.
SOAP notes
A common format for session records: Subjective, Objective, Assessment, and Plan.
Memory tipSay, Observe, Assess, Plan.
Subjective vs objective
Subjective information is what the client reports, such as pain level or feelings. Objective information is what the therapist sees, feels, or measures.
Memory tipSubjective = the client Said it. Objective = you Observed it.
Active range of motion
Movement the client does alone, using their own muscles. It tests both joint movement and the muscles that create it.
Memory tipActive = the client is the actor.
Passive range of motion
Movement the therapist performs while the client stays relaxed. It mainly tests the joint and the tissues around it, not muscle strength.
Memory tipPassive = the client just lies there.
Posture and gait assessment
Watching how the client stands and walks to notice uneven shoulders, a tilted pelvis, or a limp that may point to tight or weak areas.
Memory tipLook before you touch.
Often tested
- Take a health history before the first session and update it at each visit.
- SOAP stands for Subjective, Objective, Assessment, and Plan.
- What the client says is Subjective; what you see or measure is Objective.
- Active range of motion is done by the client; passive is done by the therapist.
- Posture and gait observation help find tight or weak areas.
Easy to confuse: Active vs passive range of motion
| Feature | Active ROM | Passive ROM |
|---|---|---|
| Who moves the limb | The client | The therapist |
| Client's muscles | Working | Relaxed |
| Mainly tests | Joint and the muscles that move it | Joint and surrounding tissues |
3 sample questions
Verified practice questions from this unit.
Question 1. In SOAP notes, what does the letter "S" stand for?
- ① Symptoms
- ② Structural
- ③ Session
- ④ Subjective
▼ Show answer and explanation▲ Hide answer and explanation
Answer: ④ Subjective
Key point: SOAP: S = Subjective
SOAP stands for Subjective, Objective, Assessment, and Plan. The S section records what the client tells you.
Wrong choices
- Symptoms: Symptoms may be written in the notes, but S stands for Subjective.
- Structural: Structural is not one of the SOAP words.
- Session: Session is not one of the SOAP words.
Question 2. Which note belongs in the Subjective section of a SOAP note?
- ① The client says her low back hurts when she sits
- ② Neck rotation to the left is limited
- ③ A tight band is felt in the upper trapezius
- ④ Right shoulder is higher than the left
▼ Show answer and explanation▲ Hide answer and explanation
Answer: ① The client says her low back hurts when she sits
Key point: Subjective = what the client says
The Subjective section holds what the client reports, such as pain, feelings, and history. The client's own words about back pain belong here.
Wrong choices
- Right shoulder is higher than the left: A posture finding the therapist sees goes in Objective.
- Neck rotation to the left is limited: A measured range of motion finding goes in Objective.
- A tight band is felt in the upper trapezius: Something the therapist feels with the hands goes in Objective.
Question 3. Which note belongs in the Objective section of a SOAP note?
- ① The client rates the pain 6 out of 10
- ② The client reports headaches three days a week
- ③ The client says work stress is high
- ④ The therapist sees the client's head sits forward
▼ Show answer and explanation▲ Hide answer and explanation
Answer: ④ The therapist sees the client's head sits forward
Key point: Objective = what the therapist observes
The Objective section holds what the therapist sees, feels, or measures. A forward head posture seen by the therapist is an objective finding.
Wrong choices
- The client reports headaches three days a week: Headaches the client reports are Subjective.
- The client says work stress is high: Stress the client describes is Subjective.
- The client rates the pain 6 out of 10: A pain rating given by the client is Subjective.