Initial Consultation Form (Pregnancy)

Client Initial Consultation Form (Pregnancy) - please complete at least 48 hours before your first appointment. If you have any problems completing the form please contact bridgnorthholistictherapies@gmail.com.

All information is held in strictest confidence, and will not be disclosed or shared without obtaining your written consent.
Name*

First NameLast Name
Mobile Number*
Email*
Occupation
Address*

Street Address

Street Address Line 2

CityCounty

Post CodeCountry
Date of birth

DayMonthYear
General State of Health

What are your current stress levels?

	1	2	3	4	5

1 is Low, 5 is High

What are your current energy levels?

	1	2	3	4	5

1 is Low, 5 is High

What is the quality of your sleep like?

	1	2	3	4	5

1 is Low, 5 is High

What is the reason for your treatment? (for example, general relaxation, or specific areas of concern)*
Are you currently taking any medication?*

YesNo
If yes, please give details:
Do you have any allergies?*

YesNo
If yes, please give details:
Medical History (Pregnancy)
Estimated due date of current pregnancy:*

DayMonthYear
Date
Is your pregnancy classified as high risk?*

YesNo
If yes, please give details:
Have you experienced any of the following?

Heavy watery or bloody vaginal dischargePre-eclampsiaUndiagnosed or abnormal abdominal painReduction in foetal movementPelvic exam/stretch and sweepComplications identified during a pregnancy scan
If you have ticked any boxes above, please give brief details and the outcome of any medical advice:
Medical History
Please indicate if any of the following apply:

High or low blood pressureHeart conditionsHistory of thrombosis/embolismCurrent or previous cancerDiabetesEpilepsyFibromyalgiaMajor operationsRecent fractures or sprainsArthritisOsteoporosisBack problemsRecent cuts or abrasionsVaricose veins or phlebitisSwelling or oedemaHeadaches/migrainesDepressionSkin conditionsRecent medical procedures (including botox)Any infectious diseasesCOVID-19 (previous 14 days)Fungal infections (such as atheletes foot)Verrucas
If you have ticked any boxes above, please give further details:
Client Declaration:

I have completed the above questionnaire fully and declare the information I have given is complete and true, and as far as I am aware I can undertake massage and reflexology with Bridgnorth Holistic Therapies without adverse effects. Any potential contra-indications highlighted by the medical questionnaire above will be discussed at the time of my appointment. I understand that massage and reflexology are not substitutes for medical examination, diagnosis or treatment. I give my informed consent to proceed.
Signature*

Clear
Sign using a touchscreen or left click and hold as you sign with your mouse or trackpad.
Date*

DayMonthYear
Should be Empty: