Prenatal Massage Intake

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Email *

Name *

Phone Number *

Address *

Email *

Current Occupation *

Estimated Due Date *

YYYY

Number of Pregnancies *

Number of Births *

Prenatal Care Provider *

Have you ever experienced a therapeutic massage before? *

Yes

Have you ever experienced pregnancy massage? *

Yes

Please List Medications and Corresponding Conditions (if applicable) *

List any Past Injuries or Surgeries *

Do you have any history of any of the following: *

High Blood Pressure

Thyroid Conditions

Morning Sickness/Nausea

Constipation

Varicose veins

Pre-term labor

Edema

Sinus congestion

Hemorrhoids

Low blood pressure

Headaches

Heartburn

Diarrhea

Other:

Required

It is my choice to receive body work. I am aware of the benefits and risks of massage and give my consent for massage. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy and reiki are not substitutes for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status.I understand that my personal health information will be collected. I understand that all information that I provide will be kept confidential unless required by law. Signature: *

Send me a copy of my responses.

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