Client Intake/Health Information Form

Client Intake/Health Information Form

Pregnancy, New Mums, Womens’ Wellness
Please ensure you complete and return this form no later than 24hrs prior to your appointment.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Post code
Phone Number
Please enter a valid phone number.Format: 0000 000 000.
Date of Birth

DayMonthYear
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 voucher reference - just the last 4 or 5 numbers. Please present either your printed 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
If born vaginally, did you experience soft tissue trauma ie episiotomy, tear?
From earlier blood tests or previous pregnancies, 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**
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.
Have you had Flu/Covid/RSV/Whooping Cough Vaccinations or Anti D injection within the last 3 days? If so, you will need to reschedule your appointment. ** Please see contraindications under T’s and C’s on my 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

ChiroOsteoKinesiologyMassageBowen TherapyAcupuncturePhysiotherapyPelvic Floor PhysioOther
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 pressureHigh blood pressure*Heart condition*Heart Arrhythmia*PIHLow lying placenta*Placenta Praevia**Vasa Praevia**Placenta Accreta**Placenta PercretaPCOSAnaemia/Low Iron**Iron Infusion within week of massage*Cerclage (stitch in cervix)*History of recurrent miscarriage*PPROM*Previous baby low birthweight on Aspirin*History of DVT on aspirin or clexane*MTHFR gene (with elevated homocysteine)*Other Clotting disorder**Maternal Factor V Leiden*Factor V Leiden (zygote)Type 1 VWD* Type 2 and 3 VWDelevated markers for Pre-eclampsia - non symptomatic**Pre-eclampsia**Cholestasis**Eclampsia**Thrombocytopenia**Intra Cranial Pressure*History of EpilepsyGestational DiabetesType 1 DiabetesInsulin pumpType 2 DiabetesThyroid - Hashimotos, Graves etcVaricose veins - legs, vulvaHaemorrhoidsPelvic Floor DysfunctionPelvic Girdle PainSPDSIJRound ligament painHip painGlute/sciatic painLeg crampsGroin painLower Back painMid back painRib painUpper back painShoulder painArm/hand pain or numbnessNeck painJaw painHeadachesAnkle/Foot painOedema/swellingOther
Are you 33+ wks and your baby is

BreechTransversePosterior
PLEASE NOW GO TO SECTIONS 3 & 4
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
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?
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)
Have you had Flu/Covid/RSV/Whooping Cough Vaccinations or Anti D injection within the last 3 days? If so, you will need to reschedule your appointment. ** Please see contraindications under T’s and C’s on my website, for full explanation **
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

ChiroOsteoKinesiologyMassageBowen TherapyAcupuncturePhysiotherapyPelvic Floor PhysioOther
Please list any of the following that relate to you

Low blood pressureHigh blood pressure*Heart Condition*Heart Arrhythmia*Pacemaker*Thrombocytopenia*Lupus*Intra Cranial Pressure*Epilepsy*DVT (on aspirin or other anti-coagulant)Type 1 DiabetesInsulin Pumpanaemia/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 DiabetesPCOSEndometriosisGastrointestinal issuesPelvic organ ProlapsePelvic floor dysfunctionExcessive/heavy periodsAbnormal bleeding between regular menstrual cyclesAbsence of monthly menstruation (please only include if you are no longer breastfeeding)PerimenopauseMenopausePostmenopauseThyroid - Hashimotos, Graves etcVaricose veins - legs, vulvaHaemorrhoidsglute tensionSciaticaLeg cramps/groin painSIJ or Symphasis Pubis painPelvic painSacrum/ tailbone painLow Back painMid back painUpper back painRib painShoulder painArm/hand pain or numbnessNeck painJaw painHeadachesAnkle/Foot painOedema/swellingOther
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..
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

LightMediumFirm
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 4 to sign, date and submit your form.
SECTION 4 : DATE & SIGNATURE
Date

DayMonthYear
Date
Signature
Should be Empty:

Client Intake/Health Information Form

Please ensure you complete and return this form no later than 24hrs prior to your appointment.

IF YOU ARE NOT PREGNANT, PLEASE GO STRAIGHT TO SECTION 2

SECTION 1: PLEASE ONLY COMPLETE THIS SECTION IF YOU ARE PREGNANT

PLEASE NOW GO TO SECTIONS 3 & 4

SECTION 2: PLEASE ONLY COMPLETE THIS SECTION IF YOU ARE NOT PREGNANT

SECTION 3: PREGNANT AND NON PREGNANT CLIENTS PLEASE COMPLETE

Thank you for sharing this information with us, please now go to Section 4 to sign, date and submit your form.

SECTION 4 : DATE & SIGNATURE