Pregnancy Health Form
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Name:
Number of Weeks Pregnant:
Your Baby's Due Date:
Name of your doctor or midwife:
What discomforts, pain, or other needs are you hoping to have addressed through massage therapy?
Have you had any complications or problems with this pregnancy?
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If yes, please check those which are applicable:
Are you currently experiencing any infection or disorder?
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If yes, please check those which are applicable:
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Is your pregnancy considered high risk?
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If yes, please check those which are applicable:
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Is there any other relevant information about this pregnancy or about you that I should know?
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