Pregnancy Massage Client Intake Form printable pdf download

Pregnancy Massage Client Intake Form

Name _____________________________________________

Birth Date _______________________

Address ___________________________________________

Telephone # _____________________

City ________________________ ST _____ Zip ___________

Email ______________________

Occupation _________________________________________

Emergency Phone Contact: Name: __________________________________Phone: _______________

How did you learn about me? ____________________________________________________________

Have you received Massage Therapy or Bodywork before? _________ What Kinds? ________________

How often? __________________________________________________________________________

Are you on any medication? _______ If yes, which ones? _____________________________________

Do you exercise? _____ How many times per week? _____ For how long? ________________________

Please list and explain other conditions/symptoms you are or have experienced:

___________________________________________________________________________________

Have you had any serious or chronic illness, operations, or traumatic accidents? ___________________

If yes, please explain: __________________________________________________________________

___________________________________________________________________________________

Prenatal Care Provider/Doctor________________________________ Telephone __________________

May I have permission to contact your Care Provider? ________

My due date is_______________.

This is my _________(number 1

, 2

, etc.) pregnancy. This will be my______ (number 1

, 2

…) birth.

I am ____(number) weeks pregnant in my ____ (1

, 2

, 3

) trimester

Pregnancy Massage Client Intake Form