Pregnancy massage consent form

Pregnancy massage consent form

Please complete in addition to The Barn’s standard consultation form.
Name
Date
How many weeks pregnant are you?
What is your due date?
Is this your first pregnancy?
Midwife/Dr contact name
Midwife/Dr contact telephone number
I am currently experiencing a low/high risk pregnancy as stated by my midwife/Dr please tick appropriate box.

LowHigh
Please carefully check and tick the list below if you have had or currently have any of the issues listed.

Abdominal crampingAnxiety, stress or depressionAnaemiaAllergiesBreathlessnessBlood clot or phlebitisbladder infectioncontagious conditionsconstipationchronic hypertensioncarpel tunnel syndromediabetesexcessive thirstfatigueHeart attacks or heart diseaseheadaches/migraineinsomnialeaking amniotic fluid/vaginal bleedingleg crampsmorning sicknessmiscarriageoedema/swellingpre term labourproblems with placentapre-eclampsia (toxemia)previous cesarean birthseparation of the rectus musclesseparation of the symphysis pubissciaticaskin disorders/conditionsuterine bleedingvaricose veinsvisual disturbanceAny other conditions or problems in previous pregnancies
Please carefully check a tick the list below if you have had or currently have any of the issues listed.

Abdominal crampingAnxiety, stress, depressionAnaemiaAllergiesBreathlessnessBlood clot or phlebitisBladder infectionContagious conditionsConstipationChronic hypertensionCarpel tunnel syndromeDiabetesExcessive thirstFatigueHeart attacks or heart diseaseHeadaches or migraineInsomniaLeaking amniotic fluid or vaginal bleedingLeg crampsMorning sicknessMiscarriageOedema or swellingPre term labourProblems with placentaPre-eclampsia (toxemia)Previous cesarean birthSeparation of the rectus musclesSeparation of the symphysis pubisSciaticaskin disorders or conditionsuterine bleedingvaricose veinsvisual disturbanceAny other conditions or problems in previous pregnancies
If I am experiencing any of the above conditions or develop complications during my pregnancy, I will fully discuss this with my massage therapist and will agree to have a medical release form signed by my midwife/Dr before commencing with any further treatment.
This form has been completed to the best of my knowledge. I fully understand that massage is a complementary treatment and does not take the place of any medical care.

All information exchanged with the therapist is strictly private and confidential and used for the sole purpose of providing the best care possible.
My GP or midwife has confirmed I am able to have massage. Signed...........

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