Fertility Massage Intake & Preferences

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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 *

Full Name *

Street Address *

City *

State *

Zip code *

Phone number *

Date of birth *

YYYY

Please send me electronic confirmations for appointments via *

Text

Please send me e-newsletters and special announcements via *

Text

Do not send me e-newsletters and special announcements

Emergency Contact (Full name) *

Relationship to emergency contact *

Phone number of emergency contact *

Current Occupation *

Have you received a professional massage before? *

Yes

If you answered yes, when was your last session?

Number of pregnancies *

Number of miscarriages *

Number of births *

Are you seeing a Fertility Specialist? *

Yes

How long have you been trying to conceive? *

List any medications (Over the counter or prescription), Vitamins and/or Herbs

List areas of discomfort, tension, stress that you would like to address

List any past or recent surgeries/Illnesses/Injuries

Are you seeking out/open to other alternative therapies? This would include herbal medicine, acupuncture and chiropractic *

Yes

Is your partner open to receiving therapeutic massage? *

Yes

Maybe

Would you both be interested in an instructional session to give you tools for working on each other? *

Yes

Maybe

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). *

YYYY

Are you cycles regular? *

Yes

Do you know when you ovulate? *

Yes

How is you and your partner's diet? Have you consulted a nutritionist or herbalist, acupuncturist about your diet? *

What do you think is inhibiting conception? *

Hormones

Congestion

Timing

Age

Diet

Lifestyle

Other

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 *

I understand

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