Pregnancy Massage/Exercise form

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal Code

Email

example@example.com

Phone Number

Area CodePhone Number

What is your occupation?

Have you or anyone in your household been diagnosed with Covid 19?

Have you or anyone in your household showed any symptoms of Covid 19 in the last 7 days?

Have you or anyone in your household been advised by the Government as being clinically vulnerable and to shield?

Have you recently travelled abroad? If yes, where to and when did you return?

Other

Have you noticed any new rashes to your body or your feet?

Please tick to confirm you will contact me if you or anyone in your household develop any of the symptoms associated with Covid 19 within 7 days of treatment

Have you noticed any unusual leg cramping?

If anything changes in your health between now and the appointment date please let me know asap. Please tick to confirm you have read this and will do so

How pregnant are you, and what is your delivery date?

Have you been pregnant before? if so how old are your children?

What were your pregnancies like, any complications at all? How is this pregnancy going?

Date of your last delivery

How were your labours? (Natural, assisted, tearing, csection)

Type a question

Details of anything ticked above

How would you describe your pelvic floor health? Do you leak urine or faeces when you exercise, laugh, sneeze or cough? Or find it hard to hold in gas?

Has your doctor ever advised that you have a heart condition?

Is there anything else you feel I should know? For example do you have any old injuries, suffer from anxiety or depression?

What is your exercise history?

Are you currently seeking help from any other professionals e.g. Physio, Chiro, osteopath

How would you rate your fitness levels out of 10? 10 being fab!

Informed Consent

I declare that the information I have given is correct.

EXERCISE

Please consult your GP or woman’s health physiotherapist before you start your new regime if you are exercising with me.

Drink lots of water or an isotonic drink throughout and after your exercise. Please wear comfortable clothing that will enable you to exercise without restriction.

As far as I am aware I am fit to undertake this exercise.

MASSAGE

I will inform Tanya if the pressure is not suitable or uncomfortable or I don’t feel happy with anything.

Informed consent

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