Client Intake & Consent

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Prenatal Intake and Health History
Name

First NameLast Name
1. In what week of pregnancy are you?*
2. What discomforts, pain, or other needs are you hoping to have addressed with massage therapy?*
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 GrowthAbnormal Fetal HeartbeatAbnormal Fetal MovementsAmniotic Fluid LeakageBleedingCrampingHeadachesHigh Blood PressureHigh Blood SugarProtein In UrineRapid Weight GainSevere NaseaSwellingVision DisturbanceVomitingOther
5. Do you have any medical conditions? Please check those that apply.

AnemiaDiabetesHeart DisordersLiver DisordersKidney DisordersLung DisordersConvulsive DisordersUterine AbnormalityConnective TissueCollagen DiseasesOther
6. Are you currently experiencing any infection or disorder? Please check those that apply.

ColdBladder InfectionBreast InfectionSkin IrritationVaricose VeinsOther
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*
9. Describe Onset of Discomfort or Pain*
10. Frequency - please select the most accurate*

ConstantOff/OnAt RestWith ActivityOther
11. At what time of day is it at its worse?*

MorningAfternoonEveningDuring SleepOther
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?*
19. Please list exercise and stress reduction activities (including frequency).*
Signature*

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