Pregnancy Massage Client Intake Form (Page 2 of 3) in pdf

Pregnancy Massage Client Intake Form

Please check (√ ) current problems, mark with (+) if you had in the past :

___ anemia

___ sciatica

___ leaking amniotic fluid *

___ separation of the rectus muscles

___ bladder infection *

___ separation of the symphysis pubis

___ uterine bleeding *

___ skin disorders/ athletes foot

___ blood clot or phlebitis *

___ twins or more! *

___ chronic hypertension *

___ varicose veins

___ abdominal cramping *

___ visual disturbances *

___ diabetes (gestational or mellitus)

___ previous cesarean birth

___ edema/swelling

___ contagious conditions

___ fatigue

___ muscle sprain / strain

___ headaches

___ heart attack / stroke

___ insomnia

___ arthritis

___ high blood pressure *

___ carpal tunnel syndrome

___ leg cramps

___ allergy to nut oils

___ miscarriage *

___ low blood pressure

___ nausea

___ bursitis

___ problems with placenta *

___ hypo or hyperglycemia

___ pre-term labor *

___ contact lens

___ preeclampsia (toxemia) *

___ other conditions or problems in current or past pregnancy___________________________________

____________________________________________________________________________________

Anything else you would like me to know? __________________________________________________

____________________________________________________________________________________

I am experiencing a low risk / high risk (circle one) pregnancy according to my doctor/midwife. If I am

currently having or develop complications (any conditions/symptoms listed above with *) I will discuss the

condition with my massage therapist, and will have a medical release for bodywork signed by my prenatal

care provider before continuing bodywork.

I have completed this health form to the best of my knowledge. I understand that Bodywork is a health aid

and does not take the place of a physician's care. Any information exchanged during a Massage or

Bodywork session is confidential and is only used to provide you with the best health care services.

If I am not able to make a scheduled appointment, I agree to cancel the appointment 24 hours in

advance. If I miss a scheduled appointment without giving 24 notice, I agree pay any missed appointment

charge.

I am responsible to pay for any Massage or Bodywork fees not paid for by my insurance company.

Name (signature) _________________________________________ Date _____________________

Pregnancy Massage Client Intake Form Page 2

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