Aromatherapy Pregnancy Massage

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Please complete this form to best of you knowledge - this will allow us to make a better informed decision about the oils to use for your massage. We only offer post dates massage - which means after your expected due date. The massage we offer is on your feet or back.

Email *

Name *

Date of birth - month/day/year *

Address *

Mobile Number *

Baby's expected due date? *

YYYY

Have you used essential oils before? *

Yes

Are there any oils you prefer to use or oils that you don't like? *

Do you have any medication condition or illnesses that you would like us to know? Please state yes or no and explain

Are you currently under any physical therapy or chiropractic treatment program?
*

Yes

Do you have any physical injuries due to sports, accidents, and others?
*

Yes

Are you breastfeeding?
*

Yes

Do you have allergies? Please state yes or no and explain.
*

Are you currently under any medication? Please explain what for
*

Do you have hypertension?
*

Yes

Do you have sensitive skin?
*

Yes

Had you experience any episode of epilepsy?
*

Yes

Have you undergone any surgical operation?
*

Yes

Can you tell us about your pregnancy - have you been well throughout or have you experienced any issues? *

Please can you tick to confirm the following that apply: This is really important information.

You have a singleton pregnancy

Your baby is lying head down in the pelvis

Your placenta is normally situated

You have no history of Haemorrhage (from previous pregnancy)

Amniotic fluid is in normal range

Your blood pressure is in normal limits

No major/medical obstetric condition

Normal fetus with no concerns around intrauterine growth

No bleeding in pregnancy

No fainting episodes in pregnancy

Please select if you have the following condition - prior to or alongside you pregnancy - we will talk to you about this.
*

Asthma

Sinus Congestion

Glucoma

Cancer

Dizziness

Headaches

Nervousness

Numbness

Arthritis

Backache

Constipation

Menopause symptoms

Hot flushes

Breast lumps

excessive urination

Cardiovascular disease

Previous stroke

Varicose veins

Chest Pain

Difficulty Breathing

Diabetes mellitus or Gestational Diabetes

Anemia

HIV

Renal disease

Deep Vein Thrombosis

None of the above apply to me

Required

Is there anything you have ticked above that you would like to explain in more detail: *

By clicking the I ACCEPT button, I agree to terms & conditions.

I am of legal age (16+) and I am aware that I will need to complete the consultation and assessment process before signing up for aromatherapy treatment. I authorize EBM/Practitioner to provide aromatherapy treatment to me on my feet or back. I understand that during the consultation, I should disclose any medical, non-medical condition that I may have so that the health and wellness practitioner can give me appropriate treatment and care. I release EBM and the Practitioner from any harm, injuries, or reactions that were caused by the treatment of the products. I also confirm that all information in this form is accurate and true to the best of my knowledge.

I accept

Required

I understand that my practitioner will discuss the blend with me and this will be agreed in response to the information i have provided in this assessment. *

I understand

A copy of your responses will be emailed to the address you provided.

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