Client Intake/Health Information Form
Pregnancy, New Mums, Womens’ Wellness
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State
Post code
Phone Number
Please enter a valid phone number.
Date of Birth
-
Day
-
Month
Year
Date
Occupation
Email
example@example.com
Emergency Contact - please provide name and number
Do you have a gift voucher to redeem? If so, please provide the last 4 numbers of your voucher. If your voucher only has 3 numbers all of these are required. Please provide your paper copy or show your digital copy at your treatment.
Sports/hobbies
IF YOU ARE NOT PREGNANT, PLEASE GO STRAIGHT TO SECTION 2
SECTION 1: PLEASE ONLY COMPLETE THIS SECTION IF YOU ARE PREGNANT
How many weeks pregnant are you?
Are you pregnant with twins or multiple babies?
Who is your Midwife, Obstetrician, GP, Doula
Please list any previous pregnancies, miscarriages, terminations, baby born sleeping
How were your previous babies born
Please Select
Vaginal Birth
Caesarean Birth
If born vaginally, did you experience soft tissue trauma ie episiotomy, tear?
From earlier blood tests, are you at risk of developing, or currently have: **please read t’s and c’s, on my website, as written medical clearance may be required prior to your massage**
Please Select
Gestational Diabetes
Pre eclampsia
Pre term birth
Have you recently had an iron infusion? a minimum 1 week between your infusion and massage is recommended - please see t’s and C’s on website for full explanation.
Please list any current (or recently completed) medications and/or natural supplements
Please list any previous injuries or surgeries
Do you use other complementary Therapies? If so, please select
Chiro
Osteo
Kinesiology
Massage
Bowen Therapy
Acupuncture
Physiotherapy
Pelvic Floor Physio
Other
Please list any of the following that relate to you currently. As some of these conditions marked * and ** are considered ‘high risk’, please review the full list of contraindications under t’s and C’s on my website; as medical clearance may be required.
Low blood pressure
High blood pressure
*PIH
Low lying placenta
*Placenta Praevia
**Vasa Praevia
**Placenta Accreta
**Placenta Percreta
PCOS
Anaemia/Low Iron
**Iron Infusion within week of massage
*Cerclage (stitch in cervix)
*History of recurrent miscarriage
*PPROM
*History of DVT on aspirin or clexane
**DVT
**Other Clotting disorder
**Maternal Factor V Leiden
*Factor V Leiden (zygote)
Type 1 VWD
* Type 2 and 3 VWD
elevated markers for Pre-eclampsia - non symptomatic
**Pre-eclampsia
**Eclampsia
**Thrombocytopenia
**Intra Cranial Pressure
*History of Epilepsy
Gestational Diabetes
Type 1 Diabetes
Insulin pump
Type 2 Diabetes
Thyroid - Hashimotos, Graves etc
Varicose veins - legs, vulva
Haemorrhoids
Pelvic Floor Dysfunction
Pelvic Girdle Pain
SPD
SIJ
Round ligament pain
Hip pain
Glute/sciatic pain
Leg cramps
Groin pain
Lower Back pain
Mid back pain
Rib pain
Upper back pain
Shoulder pain
Arm/hand pain or numbness
Neck pain
Jaw pain
Headaches
Ankle/Foot pain
Oedema/swelling
Other
Are you 33+ wks and your baby is
Breech
Transverse
Posterior
PLEASE NOW GO TO SECTIONS 3 & 5
SECTION 2: PLEASE ONLY COMPLETE THIS SECTION IF YOU ARE NOT PREGNANT
Have you given birth in the last 12 months? If so how many weeks/months since the birth of your baby?
How was your baby born
Please Select
Vaginal Birth
Caesarean Birth
If born vaginally, did you experience soft tissue trauma ie episiotomy, tear?
To best support you and maximise your comfort during your treatment, are you currently breastfeeding?
Do you have other children or perhaps now Adults? If so, how many and what are their ages?
How were they born?
Please Select
Vaginal Birth
Caesarean Birth
Do you still menstruate? Please list any issues or concerns? (Ie irregular, heavy, painful etc)
Have you recently had an iron infusion?(a minimum 1 week between your infusion and massage is recommended)
Please list any current (or recently completed) medications and/or natural supplements
Please list any previous injuries or surgeries (include caesareans, gynaecological surgeries ie hysterectomy etc.) if recent surgeries have you had a post op checkup and medical clearance?
Do you use Complementary therapies? If so, please select
Chiro
Osteo
Kinesiology
Massage
Bowen Therapy
Acupuncture
Physiotherapy
Pelvic Floor Physio
Other
Please list any of the following that relate to you
Low blood pressure
High blood pressure
*Pacemaker
*Thrombocytopenia
*Lupus
*Intra Cranial Pressure
*Epilepsy
*DVT (on aspirin or other anti-coagulant)
Type 1 Diabetes
Insulin Pump
anaemia/low iron - **if you have had an infusion within the week of your massage, please review contraindications on my website and consider rescheduling.
Type 2 Diabetes
PCOS
Endometriosis
Gastrointestinal issues
Pelvic organ Prolapse
Pelvic floor dysfunction
Excessive/heavy periods
Abnormal bleeding between regular menstrual cycles
Absence of monthly menstruation (please only include if you are no longer breastfeeding)
Perimenopause
Menopause
Postmenopause
Thyroid - Hashimotos, Graves etc
Varicose veins - legs, vulva
Haemorrhoids
glute tension
Sciatica
Leg cramps/groin pain
SIJ or Symphasis Pubis pain
Pelvic pain
Sacrum/ tailbone pain
Low Back pain
Mid back pain
Upper back pain
Rib pain
Shoulder pain
Arm/hand pain or numbness
Neck pain
Jaw pain
Headaches
Ankle/Foot pain
Oedema/swelling
Other
Do you have any physical/mobility restrictions, that require assistance? - ie difficulty getting on/off massage table, or laying on front or back for extended periods, claustrophobia etc..
PLEASE NOW GO TO SECTION 3
SECTION 3: PREGNANT AND NON PREGNANT CLIENTS PLEASE COMPLETE
Do you have any allergies or sensitivities to oils or scents? Please list
Are there any areas you do not like being massaged, or would prefer not to be included in your treatment? Please list
When selecting the type of pressure you prefer, if you have booked a ‘deep release’, this (may) include some trigger point release and is usually a medium-firm pressure
Light
Medium
Firm
Is there anything more you would like to share, not covered previously? Please feel free to comment.
Thank you for sharing this information with us, please now go to Section 5 to sign, date and submit your form.
SECTION 5 : DATE & SIGNATURE
Date
-
Day
-
Month
Year
Date
Signature
Submit
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