Fertility Massage 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 Fertility Massage 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
Current Occupation *
Your answer
Have you received a professional massage before? *
If you answered yes, when was your last session?
Your answer
Number of pregnancies *
Your answer
Number of miscarriages *
Your answer
Number of births *
Your answer
Are you seeing a Fertility Specialist? *
How long have you been trying to conceive? *
Your answer
List any medications (Over the counter or prescription), Vitamins and/or Herbs
Your answer
List areas of discomfort, tension, stress that you would like to address
Your answer
List any past or recent surgeries/Illnesses/Injuries
Your answer
Are you seeking out/open to other alternative therapies? This would include herbal medicine, acupuncture and chiropractic *
Is your partner open to receiving therapeutic massage? *
Would you both be interested in an instructional session to give you tools for working on each other? *
Date of last menstruation (If you are actively trying to conceive, appointments need to be between menses and ovulation. No fertility massage upon ovulation until menstruation). *
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DD
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YYYY
Are you cycles regular? *
Do you know when you ovulate? *
How is you and your partner's diet? Have you consulted a nutritionist or herbalist, acupuncturist about your diet? *
Your answer
What do you think is inhibiting conception? *
Required
I understand that my massage therapist does not diagnose illness, nor perform any spinal manipulations and does not prescribe any medications/treatments. I acknowledge that massage is not a substitute for a medical examination or diagnosis and that I should see my healthcare provider for those services *
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