Maternity Complementary Therapies
Name
*
First Name
Last Name
Date of birth
*
-
Day
-
Month
Year
Date
Address
*
Street Address
Street Address Line 2
City
County
Postcode
Telephone
In case of emergency please give name and number of a contact
*
Email
*
example@example.com
Occupation
Pregnancy number
*
Booked for delivery at which hospital
Expected date of delivery
*
-
Day
-
Month
Year
Date
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Previous pregnancies
Year/s
Gestation/s
Delivery type/s
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Current pregnancy
Height
*
Weight
*
Assisted conception
Please Select
Yes
No
Medications
*
Please Select
Yes
No
Hypertension /pre-eclampsia
*
Please Select
Yes
No
Diabetes
*
Please Select
Yes
No
Thyroid disease
*
Please Select
No
Yes
Neurological ie Epilepsy
*
Please Select
Yes
No
Kidney disease / urinary tract infection
*
Please Select
Yes
No
Anaemia
*
Please Select
Yes
No
Liver disease/cholestasis
*
Please Select
Yes
No
Multiple pregnancy (twins or more)
*
Please Select
Singleton
Twins
Triplets
Placenta praevia/low lying placenta
*
Please Select
Yes
No
Vaginal bleeding
*
Please Select
Before 24 weeks
After 24 weeks
None
Breech presentation
*
Please Select
Yes
No
Baby growth issues? (Big/small?)
*
Please Select
Normal growth
Big
Small
Amniotic fluid issues. Too much/little?
*
Please Select
Normal
Too much
Too little
DVT/Embolus
*
Please Select
Yes
No
Fetal movements
*
Please Select
Normal
Reduced
Details if answered yes to any questions
General wellbeing during pregnancy
Therapy booked
*
Please Select
Reflexology
Acupuncture
Moxibustion for breech baby
Any other relevant history
Client consent to treatment
Signature of client
*
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