Pregnancy Massage Client Intake Form printable pdf download

Pregnancy Massage Client Intake Form

Name___________________________________ Birth Date__________________________________

Address__________________________________ Telephone #________________________________

City____________________State_______Zip____________ Email____________________________

Occupation_______________________________

Emergency phone contact: Name___________________________Phone:________________________

How did you learn about us?_____________________________________________________________

Have you received massage therapy or bodywork before?_____________What kind?_______________

How often:___________________________________________________________________________

Are you on any medication:___________________If yes, what:_________________________________

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, explain:_________________________________________________________________________

_____________________________________________________________________________________

Prenatal Care Provider/Doctor___________________________Telephone_________________________

May I have permission to contact your care provider?_______________

My due date is________________

This is my ___________(1st, 2d, etc.) pregnancy. This will be my ___________(number 1st, 2d …) birth.

I am__________(number) weeks pregnant in my _________(1st, 2d, 3d) trimester

Pregnancy Massage Client Intake Form

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

Pregnancy Massage Client Intake Form