Prenatal Massage Client Intake Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Email *

How did you hear about me? *

Name *

Full Address *

Birth Date *

YYYY

Phone # *

Occupation *

Emergency Contact Name *

Emergency Contact Phone # *

Have you received Massage Therapy or Bodywork before? *

Yes

If yes, what kinds and how often?

Do you have any allergies to oils, lotions or dislike smells? If yes, please explain below... *

Are you on any medication? *

Yes

If yes, which ones?

Do you exercise? *

Yes

If yes, how many times per week and for how long?

Please list and explain other conditions/symptoms you are or have experienced *

Have you had any serious or chronic illness, operations, or traumatic accidents? *

Yes

If yes, please explain

Prenatal Care Provider/Doctor Name *

Prenatal Care Provider/Doctor Phone # *

May I have permission to contact your Care Provider? *

Yes

Your Due Date *

YYYY

This is my ________ pregnancy (number 1st, 2nd, 3rd, etc.) *

This will be my _________ birth

Option 1

Clear selection

How many weeks pregnant are you? *

Which trimester are you in? *

1st

2nd

3rd

Please check current problems *

anemia

leaking amniotic fluid *

bladder infection *

uterine bleeding *

blood clot or phlebitis *

chronic hypertension *

abdominal cramping *

diabetes (gestational or mellitus)

edema/swelling

fatigue

headaches

insomnia

high blood pressure *

leg cramps

miscarriage *

nausea

problems with placenta *

pre-term labor *

preeclampsia (toxemia) *

sciatica

separation of the rectus muscles

separation of the symphysis pubis

skin disorders/ athletes foot

twins or more! *

varicose veins

visual disturbances *

previous cesarean birth

contagious conditions

muscle sprain / strain

heart attack / stroke

arthritis

carpal tunnel syndrome

allergy to nut oils

low blood pressure

bursitis

hypo or hyperglycemia

contact lens

Required

List any previous but not current conditions *

Do you have other conditions or problems in your current or past pregnancies? If yes, please list. *

Is there anything else you would like me to know? *

According to my doctor/midwife, I am experiencing a: *

Low risk pregnancy

High risk pregnancy

Acknowledgments

If I am currently having or develop complications (any conditions/symptoms listed above with *) I will discuss the condition with my massage therapist and will have a medical release for bodywork signed by my prenatal care provider before continuing bodywork.

I have completed this health form to the best of my knowledge. I understand that Bodywork is a health aid and does not take the place of a physician's care. Any information exchanged during a Massage or Bodywork session is confidential and is only used to provide you with the best health care services.

If I am not able to make a scheduled appointment, I agree to cancel the appointment 24 hours in advance. If I miss a scheduled appointment without giving 24 notice, I agree to pay any missed appointment charge.

I acknowledge the information above *

Yes

Required

Send me a copy of my responses.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms