Pregnancy Massage Client Intake Form

Pregnancy Massage Client Intake Form

Therapy Center of Cedar Knolls, LLC
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Birth Date

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email address*
example@example.com
Occupation
Emergency Contact Name:*
Emergency Phone Number:*

Area CodePhone Number
How did you learn about us?*
Have you received Massage Therapy before?*
How often?*
Are you on any medication?*
If yes, which ones?
Do you exercise?
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
Your prenatal care provider's phone number

Area CodePhone Number
May I have permission to contact your Care Provider?
My due date is*

MonthDayYear
Date
1st pregnancy2nd pregnancy3rd pregnancy4th pregnancy
I am (number) weeks pregnant*
how many months
I am in my (1st, 2nd, 3rd) trimester*
Pregnancy Massage Intake Form

Please mark current/past problems
anemialeaking amniotic fluidbladder infectionuterine bleedingblood clot or phlebitischronic hypertensionabdominal crampingdiabetes (gestational or mellitus )edema/swellingfatigueheadachesinsomniahigh blood pressureleg crampsmiscarriagenauseaproblems with placentapre-term laborpreeclampsiaother conditions or problems in current past pregnancy
sciaticaseparation of the rectus muscleseparation of symphonies pubisskin disorder/athletes foottwins or morevaricose veinsvisual disturbancesprevious cesarean birthcontagious conditionmuscle sprain/strainheart attack/strokearthritiscarpal tunnel syndromeallergy to nut oilslow blood pressurebursitishypo or hyperglycemiacontact lens
Is this pregnancy low risk or high risk
Anything else you would like us 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) I will discuss the condtion with my massage therapist and will have a medical release for bodywork signed by my prenatal care 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 scheduled appointment, I agree to cancel the appointment 24 hours in advance. If I miss a scheduled appointment without giving 24 hour notice, I agree to pay any missed appointment charge.

I am responsible to pay for any Massage or Bodywork fees not paid by my insurance company.
Name (signature)*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Pregnancy Massage Client Intake Form

Pregnancy Massage Intake Form