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?
Have you experienced pregnancy massage before?
What Trimester are you in?
Expected Due Date

MonthDayYear
Date
Have you had any spotting or cramping?
Are you currently under the care of a physician?
Are you carrying multiple fetuses
Would like to include abdominal massage?
Are you currently taking any medications?
If YES, what are they and what are you taking them for?
Do you currently have any areas of discomfort?
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)
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
Should be Empty:

Summerlin’s In-Home Massage & Cupping Therapy