BROULEE MASSAGE. CONFIDENTIAL - PRENATAL CLIENT TREATMENT FORM
DO NOT FILL OUT THIS FORM BELOW UNTIL YOU HAVE READ THROUGH THE FOLLOWING INFORMATION THOROUGHLY. Your careful responses to the questions asked in this client health history online form will help your Therapist to ensure that any risks are minimised and the appropriate care is provided to you. Please note: if you currently have a HIGH RISK condition such as High Blood Pressure - you will be required to provide a MEDICAL CLEARANCE CERTIFICATE from your GP/Doctor or Midwife/Gynaecologist before you receive a treatment at Broulee Massage. Please remember your assigned therapist can only work within their scope of practice as per their certifications and level of training - depending on your health form; this may stipulate that a treatment for you may be unattainable at this present time.
I understand that only ONE client/person can attend the clinic at a time, I will arrive to my massage appointment on my own. Please reschedule if you have been unwell in the past 7 days; this is apart of our general onsite infection control policy (this excludes morning sickness & Hyperemesis Gravidarum)
YES (I will arrive on my own & have not been unwell recently)
NO (I have been unwell & will call to reschedule)
After 4 years, Broulee Massage has made the decision to implement a 50% late cancellation fee. Please keep in mind that we are a business and that late cancellations (within 24 hours) need to be accounted for. If you are on a pre-paid massage package or have an eGift Card, we will still require your Credit or Debit card details to secure your appointment(s) online from now on. We have implemented a cancellation fee to ensure that we are no longer at a loss when people fail to show up or give reasonable notice prior to their appointment.
Yes, I understand.
eGift Cards: Will you be using a Gift Voucher at the time of your treatment? If so, please bring with it with you (printed copy or phone display) and also enter your gift voucher code here below.
Medical Emergency Contact Name, Relation to you & their Contact Number
1. Are you pregnant?
2. How are you feeling today?
3. Is this your first Pregnancy?
4. How many weeks gestation are you?
5. Are you taking any current medications?
6. Have you had a professional Pre-Natal Massage before from a certified Pre-Natal Massage Therapist? (*please note that under the guidelines for Pregnancy Massage Australia - it is deemed best practice that a professional Prenatal Massage to be performed in a side-lying position from 10 weeks gestation).
7. When was your last Pre-Natal check up approximately? Was everything considered good/healthy/well with your current Pregnancy? Also, do you recall your Blood Pressure reading? (*please answer all 3 qu's).
8. What are your current areas of tension & what how would you describe the best treatment outcome for you in your Pre-Natal Massage? (*please answer all 2 qu's).
9. Do you/have you have/got any of the following at present? (please select as many that may apply).
Accidents i.e. recent fall, car accident etc
Allergies or skin problems
Attention deficit hyperactivity disorder
Blood Clots or Thrombophlebitis
Chronic Hypertension/Gestational Preeclampsia
Heart/Blood Circulation Disorders
Lower Back Pain
Obsessive Compulsive Disorder
Post Traumatic Stress Disorder
Separation of Symphysis Pubis
Separation of Abdominal Muscles
Vomiting (24 hours consistent)
More than 2 Consecutive Miscarriages
NONE OF THE ABOVE
10. If you selected any of the conditions above, please provide us with more information below: ( i.e. I am experiencing uterine bleeding but my doctor has explained this is normal due to (the reason) and I have been given medical clearance for Massage).
This is the Consent section in order to receive a Pre-Natal Massage treatment from a trained Pre-Natal Therapist from Broulee Massage. Please read the disclaimer thoroughly.
According to my DOCTOR/MIDWIFE I am experiencing a:
Low Risk Pregnancy
High Risk Pregnancy
I, (please print/type your full name):
understand, that if I am currently having or develop complications, 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 have completed the massage intake form and all information is true and correct. I understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain, discomfort or suddenly feel unwell during this session, I will immediately inform my therapist, so that the pressure and/or strokes may be adjusted to my level of comfort or that we may have to cease treatment. I understand that it is best practice that massage pressure application in the treatment will range from light – medium (4 – 5 / 10) and that there are acupressure points on the body that my therapist will need to avoid as best practice regarding my pregnancy. I understand that the guidelines for Pregnancy Massage in Australia deem that it is best practice for a professional Pre - Natal Massage to be performed in a side-lying position from 10 weeks gestation. I further understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment, and that I should see a physician or other qualified medical specialist for any mental or physical ailment that I am aware of. Massage should not be performed under certain high risk medical conditions, I affirm that I have stated all my known medical conditions and I have answered all questions honestly.
Yes, I do consent to the above information:
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