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Prenatal Intake and Health History
Name
First Name
Last Name
1. In what week of pregnancy are you?
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Please Select
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40+
2. What discomforts, pain, or other needs are you hoping to have addressed with massage therapy?
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3. Are you regularly seeing a physician, nurse-midwife, or midwide? Please provide name and phone number.
*
4. Have you had any complications or problems with this pregnancy? Please check those that apply:
Abnormal Fetal Growth
Abnormal Fetal Heartbeat
Abnormal Fetal Movements
Amniotic Fluid Leakage
Bleeding
Cramping
Headaches
High Blood Pressure
High Blood Sugar
Protein In Urine
Rapid Weight Gain
Severe Nasea
Swelling
Vision Disturbance
Vomiting
Other
5. Do you have any medical conditions? Please check those that apply.
Anemia
Diabetes
Heart Disorders
Liver Disorders
Kidney Disorders
Lung Disorders
Convulsive Disorders
Uterine Abnormality
Connective Tissue
Collagen Diseases
Other
6. Are you currently experiencing any infection or disorder? Please check those that apply.
Cold
Bladder Infection
Breast Infection
Skin Irritation
Varicose Veins
Other
7. Is your preganancy considered to be high risk (due to diabetes, hypertension, multiple pregnancy, previous complicated pregnancy, asthma, Rh or genetic problems, age under 20 or over 35 years of ages, fetal genetic disorders, or exposure to hazardous materials)?
8. List Areas of Discomfort or Pain
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9. Describe Onset of Discomfort or Pain
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10. Frequency - please select the most accurate
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Constant
Off/On
At Rest
With Activity
Other
11. At what time of day is it at its worse?
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Morning
Afternoon
Evening
During Sleep
Other
15. Have you ever received therapeutic massage for a specific problem or injury?
16. Is there anything that you do that creates, increases or decreases pain?
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19. Please list exercise and stress reduction activities (including frequency).
*
Signature
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Date
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Month
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Day
Year
Date
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