Pregnancy Intake Form

Summerlin’s In-Home Massage & Cupping Therapy

Pregnancy Intake Form
Client Name*

First NameLast Name
Birthday*

MonthDayYear
Date
Phone Number*

Area CodePhone Number
Email*
example@example.com
Have you experienced therapeutic massage before?*

YesNo
Have you experienced pregnancy massage before?*

YesNo
What Trimester are you in?*

FirstSecondThird
Expected Due Date*

MonthDayYear
Date
Have you had any spotting or cramping?*

YesNo
Are you currently under the care of a physician?*

YesNo
Are you carrying multiple fetuses*

YesNo
Would like to include abdominal massage?*

YesNo
Are you currently taking any medications?*

YesNo
If YES, what are they and what are you taking them for?
Do you currently have any areas of discomfort?*

YesNo
If YES, what are they?
Do you have any past injuries or surgeries that I should know about?
Medical History
Do you have any history of (please check any that apply)*

High Blood PressureLow Blood PressureThyroid ProblemsMorning sickness/NauseaSensitive to scentsConstipationVaricose VeinsEdemaSinus congestionHemorrhoidsHeadachesHeartburnDiarrheaNone
Authorization
I agree that I have read, understand, and that I have filled out this intake form to the best of my knowledge. I agree to allow Jenna Swaney to perform a Pregnancy Massage on me. I have had the opportunity to ask any questions and by signing below I agree to release Jenna Swaney from any liability in connections with receiving a Pregnancy Massage.
Name*

First NameLast Name
Signature of the Patient*

Clear
Should be Empty:

Summerlin’s In-Home Massage & Cupping Therapy

Medical History

Authorization