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.

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Email address *
Full Name *
Street Address *
City *
State *
Zip code *
Phone number *
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) *
Relationship to emergency contact *
Phone number of emergency contact *
Have you received a professional massage before? *
If you answered yes, when was your last professional massage?
How much water do you drink daily? *
Please list areas of tension, stress or pain you wish to be addressed
Please list current medications (over the counter and prescription), vitamins and herbs
Please list any surgeries, illnesses or injuries (past or present)
Please list any known allergies (skin or internal) to oils, plants, flowers, seeds, nuts
PreNatal Care Provider Name and Number *
Due Date: *
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How many weeks? *
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
Does your doctor consider your pregnancy high risk or low risk? *
If you answered High risk, please explain why
Do you exercise? *
If you answered yes, please provide type and frequency.
How did you hear about me?
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