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Pregnancy Massage
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Pre Appointment Forms
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Home
About
Services
Sports Massage
Kinesiology Taping
Normatec Pulse Pro Recovery
Pregnancy Massage
Contact
Times & Prices
Pre Appointment Forms
Book Now
Pre Appointment Sports Massage Forms
Sports Massage Client Intake form
Sports Massage Client Intake Form
Name
*
First Name
Last Name
Email
*
Reason For Your Visit
*
Please outline the key reason(s) for your appointment (e.g. specific injury; general recovery etc) and what the goals are of your treatment.
Medical Information (All information is strictly confidential).
Are you taking any medications?
Yes
No
If yes, please list name and use:
Are you currently pregnant?
Yes
No
If yes, how far along & please specify any high risk factors:
Do you suffer from chronic pain?
Yes
No
If yes, please explain. What makes it better? What makes it worse?
Have you had any orthopedic injuries?
Yes
No
If yes, please list:
Please indicate any of the following that apply to you:
Cancer
Headaches/Migraines
Arthritis
Diabetes
Joint Replacement
High Blood Pressure
Low Blood Pressure
Neuropathy
Fibromyalgia
Stroke
Heart Attack
Kidney Dysfunction
Blood Clots
Numbness
Sprains or Strains
Provide further details of any conditions marked above:
MASSAGE INFORMATION
Have you had a professional sports massage before?
Yes
No
What pressure do you prefer?
Light
Moderate
Deep
Do you have any allergies or sensitivities?
Yes
No
If yes, please detail here:
Are there any areas you do not want to be massaged? (e.g. feet, neck etc.)
Yes
No
If yes, please detail here:
Please indicate below whether you agree to the following:
*
I have competed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at any time.
Yes
No
Thank you!
Pregnancy Massage Client intake Form
Pregnancy Massage Client Intake Form
Name
*
First Name
Last Name
Email
*
Date of Birth
MM
DD
YYYY
How many weeks pregnant are you?
*
When is your due date?
*
MM
DD
YYYY
Is this your first pregnancy?
*
Yes
No
If not, how old is/are your previous children?
*
Do you have consent from your GP/midwife to have a pregnancy massage?
Yes
No
How has your current pregnancy been? Please include any medical comments, if relevant.
*
Are there any pre-existing health conditions to be aware of?
*
Please list and ailments you may be suffering from. For example: backache, anxiety, SPD, heartburn etc.
*
Are you currently under obstetric care?
*
Yes
No
If yes, please state why.
*
How would you describe your overall well being taking into account your physical, mental and emotional state?
*
What date was your last check -up with a midwife or GP?
*
MM
DD
YYYY
Were there any comments/actions following this last check-up?
*
Are you taking any medication?
*
Have you had any recent operations (including C-section)? Please state the date of operation if applicable.
*
Have you suffered from, or are currently suffering from any of the following symptoms? Please tick to indicate 'Yes'.
Chest Pain
Palpitations
High Blood Pressure
Low Blood Pressure
Asthma
Shortness of Breath
Nausea
Reflux
Sciatica
Separation of the Symphysis Pubis
Carpal Tunnel Syndrome
Problems with the Placenta
Leg Cramps
Anemia
Bladder Infection
Uterine Bleeding
*
Any other conditions or problems in your current or previous pregnancies?
Is there any reason (medical or otherwise) why you think you should not be able to have a pregnancy massage?
Yes
No
I have competed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at any time.
Yes
No
*
Client Signature/Initials & Date.
Thank you!
