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

___anemia

___muscle sprain/strain

___sciatica

___headaches

___leaking amniotic fluid*

___heart attack/stroke

___separation of the rectus muscles

___insomnia

___bladder infection*

___arthritis

___separation of the symphysis pubis

___high blood pressure

___uterine bleeding

___carpal tunnel syndrome

___skin disorders/athletes foot

___leg cramps

___blood clot or phlebitis*

___allergy to nut oils

___twins or more !*

___miscarriage*

___chronic hypertension

___low blood pressure

___varicose veins

___nausea

___abdominal cramping*

___bursitis

___visual disturbances*

___problems with placenta*

___diabetes (gestational or mellitus)

___hypo or hyperglycemia

___previous cesarean birth

___pre-term labor

___edema/swelling

___contact lens

___contagious conditions

___preeclampsia (toxemia)*

___fatigue

___allergies (i.e., peanut oil)

___other conditions or problems in current or past pregnancy___________________________________

_____________________________________________________________________________________

Anything else you would like for 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 symptoms/conditions 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 will immediately let my therapist know of any

pain or discomfort so that pressure and strokes can be adjusted to my level of comfort.

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. I

know that massage/bodywork can be harmful in some circumstances; I fully assume responsibility for

receipt of massage therapy, and release and discharge the therapist from any and all claims, liabilities,

damages, actions from therapy received. I fully and fairly answered these questions and described my

health and will tell the practitioner of any changes.

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

advance. If I am late for my appointment, I understand that I will pay the full fee for the time allotted

me.

Name__________________________________________ Date_______________________________

Pregnancy Massage Client Intake Form Page 2

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