Pregnancy Massage Consultation Form

Please complete the details below before your therapy. This form will then be stored in accordance with GDPR Regulations and has a 356 encryption key for optimum security.
PREGNANCY MASSAGE CONSULTATION FORM
Name*

First NameLast Name
Date of Birth

DayMonthYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Mobile Number:*
Occupation:
How did you hear about Holistic Habitat Therapies?
List any medications, supplements, or herbal remedies you currently take:*
Please list allergies or sensitivities:*
Please list Injuries or surgeries:*
If you have had a massage before, when was it?*

DayMonthYear
Date
What type was it - e.g. swedish?*
Do you exercise?*
How many times per week and for how long?*
Please list and explain other conditions/symptoms you are or have experienced?*
Have you had any serious or chronic illness, operations, or traumatic accidents? If yes, please explain.*
Pre-natal Care Provider/doctor name:*
In case of an emergency
Their Telephone please:*
May I have permission to contact your care provider?*
In case I find something I am concerned about and you can't answer.
My due date is:*

DayMonthYear
Date
This will be my:*

1st pregnancy2nd pregnancy3rd pregnancy4th pregnancy
This will be my:*

1st birth2nd birth3rd birth4th birth
How many weeks pregnant are you?*

1st trimester - 1 - 13 weeks2nd trimester - 14 - 26 weeks3rd trimester - 27 - 40 weeksList your week No. here
Please indicate if you have any of the conditions below:
Symptoms under A:*

Abdominal cramping*Allergies (eg. nut oils)AnaemiaAnxiety, stress or mood swingsAsthmaNone of the above
Symptoms under B:*

Bladder infection*Blood clot or phlebitis*BreathlessnessNone of the above
Symptoms under C:*

Carpal tunnel syndromeChronic Hypertension*Contagious conditionsConstipationNone of the above
Symptoms under D/E/F:*

Diabetes (gestational or mellitus)Excess ThirstFatigueNone of the above
Symptoms under H/I:*

HeadachesHeartburnHeart attack/strokeHigh blood pressure*InsomniaNone of the above
Symptoms under L/M/N:*

Leg CrampsLow blood pressureMiscarriage*Morning sicknessMuscle sprain/strainNauseaNone of the above
Symptoms under O/P:*

Oedema/swellingPre-eclampsia (toxaemia)*Pre-term labour*Previous caesarean birthProblems with placentaNone of the above
Symptoms under Q/R/S/T/U/V/W/X/Y/Z:*

SciaticaSeparation of the rectus musclesSeparation of the symphysis pubisSkin disorder/athletes footUterine bleeding*Varicose veinsVisual disturbances*None of the above
Is there anything else I need to know or other conditions or problems in current or past pregnancy?*
By SUBMITTING THIS FORM, you agree to the following:

1) I have clearance from my pre-natal care provider to receive pregnancy massage therapy.

2) I understand that pregnancy massage is a health aid and not a substitute for traditional medical treatment or medications.

3) If I am currently having or develop complications (any conditions/symptoms listed above with*), I will discuss the condition with Bronwen as soon as possible.

4) I understand the risks associated with massage therapy include, but are not limited to:

• Superficial bruising or redness

• Short-term muscle soreness

• Exacerbation of undiscovered injury

I, therefore, release Holistic Habitat Therapies (Bronwen) from all liability concerning these injuries that may occur during the massage session.

6) I understand the importance of informing Bronwen of all medical conditions and medications I am taking, and to let her know about any changes to these. I understand that there may be additional risks based on my physical condition.

7) I understand that it is my responsibility to inform Bronwen of any discomfort I may feel during the session so she may adjust accordingly.

8) I understand that I or Bronwen may terminate the session at any time.

9) I have been given a chance to ask questions about the session and my questions have been answered.

10) Please be considerate and give at least 24 hours notice or more if you are unable to attend or you may be charged a nominal cancellation charge.

If you prefer paying by BACS, it would be much appreciated if you could pay for your first therapy in advance so your BACS details are set up for future therapies. You can amend your booking.

Please send your BACS payments to:

Mrs B Pretorius

Sort Code: 20-24-09
Account no: 40208752

Reference: Massage

Please be assured that any information exchanged during a massage session is confidential and is only used to provide you with the best health care service.
Date*

DayMonthYear
Date
Please verify that you are human*
Clinic Use only.
Should be Empty:

PREGNANCY MASSAGE CONSULTATION FORM

Please indicate if you have any of the conditions below: