Massage/Reiki Intake/Health Information Form

Massage/Reiki Intake/Health Information Form

Pregnancy, New Mums, Womens’ Wellness
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Post code
Phone Number
Please enter a valid phone number.
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 voucher number (just the last 4 digits only). You must provide your paper or show your digital copy.
Sports/hobbies
IF YOU HAVE BOOKED A REIKI SESSION ONLY AND YOU ARE NOT PREGNANT, PLEASE GO STRAIGHT TO SECTION 2
SECTION 1: PLEASE ONLY COMPLETE THIS SECTION IF 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, are you at risk of developing, or currently have:
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
Do you use other complementary Therapies? If so, please select

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

Low blood pressureHigh blood pressureLow lying placentaPlacenta PraeviaPCOSAnaemia/Low IronCerclage (stitch in cervix)Factor V LeidenOther Clotting disorderHistory of DVTGestational 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 & 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
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)
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

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

Low blood pressureHigh blood pressurePacemakerType 1 DiabetesInsulin PumpType 2 DiabetesAnaemia/low ironPCOSEndometriosisGastrointestinal issuesPelvic organ ProlapsePelvic floor dysfunctionExcessive/heavy periodsAbnormal bleeding between regular menstrual cyclesAbsence of monthly menstruation (please only include if you are no longer breastfeeding)PerimenopauseMenopausePostmenopauseDVTThyroid - 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..
PLEASE NOW GO TO SECTION 3 (OR 4 IF HAVING REIKI ONLY)
SECTION 3: MASSAGE CLIENTS ONLY (IF REIKI, PLEASE GO TO SECTION 4)
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
What type of massage pressure do you like?

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 5 to sign, date and submit your form.
SECTION 4 : REIKI CLIENTS ONLY
Have you had Reiki before?
Do you have any allergies or sensitivities to essential oils or scents? Please list
All efforts are made to ensure you feel comfortable and safe. Please let us know if you have any physical limitations i.e. claustrophobic, overheats, feels excessive cold, getting on and off table, unable to lie on front or back for extended periods of time etc.? Please list
What areas of your life would you like to work with? i.e. overcoming health/physical/mental/emotional/ spiritual issues, or setting and accomplishing goals
Expectations for seeking treatment?
To help with the balancing and cleansing elements of your Session and to help calm the parasympathetic nervous system; it is recommended that you reduce (where possible) stimulants like caffeine, alcohol and recreational drugs, at least 12-24hrs prior to your Session.
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

DayMonthYear
Date
Signature

Clear
Should be Empty:

Massage/Reiki Intake/Health Information Form

IF YOU HAVE BOOKED A REIKI SESSION ONLY AND YOU ARE NOT PREGNANT, PLEASE GO STRAIGHT TO SECTION 2

SECTION 1: PLEASE ONLY COMPLETE THIS SECTION IF PREGNANT

PLEASE NOW GO TO SECTIONS 3 & 5

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

PLEASE NOW GO TO SECTION 3 (OR 4 IF HAVING REIKI ONLY)

SECTION 3: MASSAGE CLIENTS ONLY (IF REIKI, PLEASE GO TO SECTION 4)

Thank you for sharing this information with us, please now go to Section 5 to sign, date and submit your form.

SECTION 4 : REIKI CLIENTS ONLY

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