New Client Consultation Form

Alejandra Hajduk LMT Client Pregnancy Treatment Consultation Form

The following information will be used to help plan a safe and effective treatment. Please answer the questions to the best of your knowledge. All information will remain private & confidential.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

City

Country
Date of Birth*

MonthDayYear
Date
Phone Number*

PrefixPhone Number
E-mail*
Occupation
Primary Care Provider Name & Address*
Last visit to Primary Care Provider*

MonthDayYear
Date
Emergency Contact Name & Mobile*
Pregnancy Week*
Due Date*

MonthDayYear
Date
Pregnancy Information:
Do you suffer from any of the following pregnancy related conditions?*

BackacheMorning SicknessHeartburnHeadaches / MigraineSinusesDepression / Anxiety / Panic AttacksDiarrhea / Constipation / IBSSciaticaAnemiaOedema (Swelling)High Blood PressureLow Blood PressurePalpationsVaricose VeinsHaemorrhoidsPelvic Girdle InstabilitySymphysis Pubis LaxityCapal Tunnel SyndromeVaginal BleedingAbdominal PainSensory Loss (numbness)Urination IssuesLeg Cramping / PainClotting issue (suspected deep vein thrombosis)Protein, sugar or blood in urineAny other conditions not listed here (please go into detail below)None of the aboveOther
Please specify if you marked any of the above, when did it start, treatment received, is it ongoing?
Current Medications (incl vitamins):*
Your General Health
Stress Levels at Home*

HighMediumLow
Are you currently working outside the home (occupation please if yes)?
Stress Levels at Work*

HighMediumLown/a
Exercise/Hobbies?
How would you describe your current emotional state?
Have you experienced any of these health conditions in the past or present?*

Covid-19Hormone Imbalance (eg PCOS / irregular cycle)CancerHigh Blood PressureDiabetesHeart problemArthritisAuto-Immune DisordersAsthmaEpilepsy / Seizure DisorderFever BlistersHerpesFrequent Cold SoresHIV/AIDSLupusDepression/AnxietyHepatitisHeadaches / MigrainesEndometriosisN/AOther
If you checked yes to any of these please provide further information. If not mark N/A
Any known allergies/sensitivities (eg: latex, nuts, essential oils)? If so, which? *
What is your daily water intake (glasses)
How many hours of sleep do you receive each night?
What is your sleeping position?
Are you currently in pain or experiencing any discomfort? If so, please briefly explain and name those areas below.
What makes it better?
What makes it worse?
What specific areas would you like for me to focus on or stay away from?
What do you hope to accomplish with this massage? (i.e. relaxation, decrease back pain, increase flexibility, emotional support, all of the above...)
Is there any other information you would like to make your therapist aware of? If yes, please give details:
Reservation & Cancellation Policy for all current and future appointments: In the event of cancellations received less than 24 hours prior to appointment a cancellation fee equal to the reserved service booking will incur. No Shows will be charged 100%. Suspected Covid-19 and severe pregnancy related issues are exceptions to this rule, but please do let me know asap*

I understand the reservation and cancellation policies at Renew Therapies and consent to my credit card on file being charged if I fail to give the required notice.
I knowingly and willingly consent to attending for a complimentary treatment during the COVID-19 pandemic. The therapist will remain masked for the duration of the session while the client can remove theirs, as long as they are vaccinated.*

By checking this box I understand and accept this statement
I occasionally contact clients to follow up on a session and I also send booking confirmation and a reminder via email / SMS. I occasionally send emails regarding updates, special offers etc. You may unsubscribe from these emails at any time. Please confirm you give your permission to:*

Contact you about appointment and relevant follow up.Send occasional emails with news, special offers etc.
Massage during pregnancy provides many benefits. It enhances circulation, supporting the work of your heart, and increasing the oxygen and nutrients delivered to your baby. It can relieve the sensation of heaviness and aching in your legs caused by swelling or varicose veins. It can optimize your muscle tone and function, relieve muscle strain and fatigue, and reduce strain on your joints. Pregnancy massage reduces stress and promotes relaxation, contributing to a healthier pregnancy.

If you have been told your pregnancy is high-risk, please notify the therapist. Please read and sign the acknowledgement below:

I have received and read written information concerning the possible benefits of massage therapy during pregnancy.

I verify that I am experiencing a low-risk pregnancy, and have stated all my known medical conditions and take it upon myself to keep the therapist/practitioner updated on my health.

I understand that I will be receiving massage therapy for the purpose of stress reduction, relief from muscle tension or spasm, or for increasing circulation and energy flow.

I understand that the massage therapist does not diagnose illness, and as such, the massage therapist does not prescribe medical treatment or pharmaceuticals, nor do they perform any spinal manipulations.

I am aware that this massage is not a substitute for medical examination/diagnosis and that it is recommended that I see a physician for any ailment that I might have.

I understand and agree that I am receiving massage therapy entirely at my own risk. In the event that I become injured either direction or indirectly as a result, in whole or in part, of the aforesaid massage therapy, I HEREBY HOLD HARMLESS AND INDEMNIFY the therapist, their principals, and agents from all claims and liability whatsoever.

I understand that payment is due at the time of treatment unless arrangements have been made otherwise.
Signature*

Clear
Thank you for taking the time to complete this form - I look forward to seeing you soon. Alejandra Hajduk LMT
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Alejandra Hajduk LMT Client Pregnancy Treatment Consultation Form

Pregnancy Information:

Your General Health