PreNatal Client Intake & Preferences
Eileen Monaghan, LMT | 757.553.4052 | 3630 South Plaza Trail, Suite 110 Virginia Beach, VA 23452 www.monaghan-massage.com | www.hrprenatalmassage.com

Please complete this brief Client Intake & Preferences form to the best of your knowledge before your first appointment. The following information will be used to help plan safe and effective massage sessions. It will be kept confidential, unless a separate Release Form is signed.
Email address *
Your answer
Full Name *
Your answer
Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip code *
Your answer
Phone number *
Your answer
Date of Birth *
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Please send me electronic confirmations for appointments via: *
Please send me e-newsletters and special announcements via: *
Emergency Contact (Full name) *
Your answer
Relationship to emergency contact *
Your answer
Phone number of emergency contact *
Your answer
Have you received a professional massage before? *
If you answered yes, when was your last professional massage?
Your answer
How much water do you drink daily? *
Your answer
Please list areas of tension, stress or pain you wish to be addressed
Your answer
Please list current medications (over the counter and prescription), vitamins and herbs
Your answer
Please list any surgeries, illnesses or injuries (past or present)
Your answer
Please list any known allergies (skin or internal) to oils, plants, flowers, seeds, nuts
Your answer
PreNatal Care Provider Name and Number *
Your answer
Due Date: *
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How many weeks? *
Your answer
In order to provide you with the best possible care during your pregnancy, it helps me to know of any complications or conditions that may require particular bodywork precautions. Please inform me of any changes in your pregnancy at each visit. Please check any conditions that you have dealt with (past or present)
Provide details of any other problems in current or past pregnancies
Your answer
Does your doctor consider your pregnancy high risk or low risk? *
If you answered High risk, please explain why
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Do you exercise? *
If you answered yes, please provide type and frequency.
Your answer
How did you hear about me?
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