Prenatal Intake Form
Name
First Name
Last Name
Date
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Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
How did you hear about Massage By Becky?
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General Questions:
How are you feeling today? (emotionally, physically?)
How far along are you?
Have you ever received a prenatal massage before? If so, how long ago?
What would you like from your treatment today?
What level of pressure do you prefer?
Light
Medium
Deep
Any areas you would like special attention to?
Any areas you would like avoided?
Are you allergic or sensitive to any creams?
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Occupational Questions:
What is your main activity at work?
Phone
Sitting
Computer
Labor
Driving
What physical activities do you participate in regularly?
Medical History
Please list current medications:
Any side effects?
List accidents/injuries along with date of incident:
Have you ever been diagnosed with cancer? If so, what type and when?
Have you ever had a related sports injury? If so, what type?
Have you been diagnosed with any prenatal complications? If so, what type?
Check any or all that apply to your present health:
Headaches
Inflammation
Carpal tunnel
Jaw pain/tmj
athletes foot
depression/anxiety
PTSD
Fibromyalgia
Chronic pain
Muscle/joint pain
Numbness/tingling
Sprains/strains
Stent/shunt/pacemaker
Spinal abnormalitites
Arthritis
Tendonitis
Herniated disk
Varicose veins
Blood clots (dvt)
High/low blood pressure
Diabetes/hypoglycemic
MS/parkinson's/lymes/lupus
Cancer/tumors
Infectious disease
Contagious skin disorders
Wounds/rashes/skin cancer
Other
Breast Implants?/When?
Reconstructive/Aesthetic?
To comply with informed consent, I will discuss the following with you before your treatment: 1. What to expect from your prenatal massage treatment 2. Proposed treatment plan and goals 3. Explanation of the pressure I will be using during treatment 4. Any contraindications or precautions for receiving prenatal massage.
PLEASE TAKE A MOMENT TO CAREFULLY READ THE FOLLOWING INFORMATION AND SIGN WHERE INDICATED: I understand that the massage/bodywork I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and or strokes may be adjusted to my level of comfort. I further understand that massage/bodywork should not be construed as a substitute for an examination, diagnosis or treatment of disease/injuries. I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there should be no liability on the practitioner's part should I forget to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in the termination of the session, and I will be responsible for payment of the scheduled session. I agree and adhere to the cancellation policy set forth and will be responsible for charges if I fail to show up for my scheduled appointment.
Signature
Date
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Month
-
Day
Year
Date
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