Prenatal Intake
Please fill out at least 24 hours before your session
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Birthday
-
Month
-
Day
Year
Date
Age
Occupation
Employer
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Relationship of Emergency Contact
How did you hear about us? Please be specific.
General Medical Information
Are you currently pregnant?
Yes
No
Are you currently taking any medications?
Yes
No
Please list and explain the medications you are currently taking.
If you currently exercise, please describe the nature and duration of your physical activity:
Which, of any of the following are you currently experiencing?
Anemia
Insomnia
Sciatica
Varicose Viens
Arthritis
Autoimmune Disorder
Headache
Scoliosis (mild or severe)
Muscle Sprain/Strain
IT Band Syndrome
Hyperglycemia
Hypoglycemia
Stabbing Pains
Fatigue
Nausea
Skin Disorders or Rashes
Contagious Conditions
Bursitis
Edema/Swelling
Leg Cramps
Low Blood Pressure
High Blood Pressure
Carpel Tunnel Syndrome
Piriformis Syndrome
Allergies to Nut Oils
Numbness/Tingling
Other
Have you had any serious or chronic illness, operations or traumatic accidents? If so, please explain:
Massage Preferences
We'd love to know your general preferences for massage therapy so we can best meet your needs. We realize some of this might change any given session as your needs change; if so, please let your therapist know of any changes/requests before every session. If you are new to massage, just fill this out to the best of your ability.
Have you received massage before? If so, roughly how long has it been since your last massage?
Preferred Pressure/Intensity
A good massage is not so deep that you flinch or tense up, but deep enough that it feels good to you.
GENERALLY SPEAKING, on a scale of 1-10, what depth of pressure/intensity feels perfect to you? (0 being light touch, 5 moderate pressure, 10 deep as can be)
How Time is Spent: GENERALLY SPEAKING, are there any areas you want us to skip entirely, either because you don't like it, or because you want to allocate more time elsewhere?
Please let us know the things you really love in a massage: (For example, "I LOVE my scalp worked!")
Please let us know anything that annoys you or leaves you disappointed in a massage: (We'd like to NOT do those things!)
Do you currently have specific areas of complaint or tension?
PLEASE TELL US WHAT YOU HOPE TO ACCOMPLISH DURING YOUR SESSIOn:
Pregnancy Specific Information
Prenatal (currently pregnant) and Postpartum (up to 16 weeks post pregnancy)
For Prenatal, what is your estimated due date? For Postpartum, when did you last give birth?
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Month
-
Day
Year
Date
For prenatal: how many weeks into your pregnancy are you currently? For postpartum: how many weeks postpartum are you currently?
For Prenatal: what number of pregnancy is this for you? For Postpartum: what number of pregnancy was this for you?
For Prenatal: what number baby will this be for you? For Postpartum: what number baby was this for you?
Is your pregnancy considered low-risk (normal) or high-risk (complications)?
High Risk Concerns: It is extremely important that you let us know if you are experiencing any of the following symptoms/issues, as they may require that we obtain a Physician/Midwife release form prior to your session.
Bladder Infection(s)
Blood Clot or Phlebitis
Diabetes or Gestation Mellitus
Placenta Problems (Previa, Abruption, etc.)
Leaking Amniotic Fluid
Uterine Bleeding
Chronic Hypertension (High Blood Pressure)
Pre-Term Labor
Disturbance in Vision (spots, flashes, etc.)
None of the above
Other
Outside of pregnancy-related issues, have you had any serious or chronic illness, operations or traumatic accidents? If so, please explain:
Who is your prenatal care provider? (Name of your doctor or Midwife)
Do we have permission to contact your prenatal care provider if consultation is required? (For example, if a release form is required for massage due to serious conditions or to discuss specific issues that may affect our work with you)
Yes
No
Policies, Terms & Conditions
I have stated all my known medical conditions and take it upon myself to keep my therapist updated on changes to my physical health. I understand that any information exchanged during a session is kept confidential. If I am currently having or at any future point develop complications or serious conditions affecting my health, I will notify my massage therapist prior to my session, and will have a medical release for bodywork signed by my healthcare provider before receiving massage therapy. I understand that the massage therapy given here is for the purpose of stress reduction, relaxation, relief from muscular tension, or for increasing circulation, balance and body awareness. I understand that the therapist does not diagnose illness, disease, or any other physical or mental disorder, nor do they prescribe medical treatment, pharmaceuticals, nor do they perform any spinal manipulations. I understand that massage therapy is not a substitute for treatment from a physician, medical examination and/or diagnosis and that it is recommended that I see a physician for any physical ailment and that I have regular prenatal care if pregnant.
I Agree
I do forever release Relax & Revitalize LLC, DBA North Florida Therapeutic Massage and their insurers, their respective officers, directors, stockholders, successors, employees, contractors and agents from all liability of any nature whatsoever, whether past, present, or future for any injury or damage which may occur to myself or my family as a result of my receiving massage therapy and bodywork from this point forward. I agree to hold harmless and defend the practitioner of and from all actions, claims, or other legal or administrative action that has arisen or may arise directly or indirectly out of my participation in this therapy. I have completed this health form to the best of my knowledge. By agreeing to and submitting this form, I agree to abide by the polices, terms and conditions set forth and I realize these policies may change at any time without notice.
*
I Agree
CANCELLATIONS/RESCHEDULING: If I am not able to make a scheduled appointment, I agree to cancel or reschedule the appointment AT LEAST 48 hours in advance. I agree to pay $60 or 50% of the full session rate (whichever is greater) if I give less than 24 hours notice. If I have a contagious illness, or have a sudden, unplanned health or personal emergency that will cause me to miss my appointment I agree to inform North Florida Therapeutic Massage immediately, but agree to pay the cancellation fee unless North Florida Therapeutic Massage decides to grant an exception to my circumstance. I agree to pay the full session rate if I give 2 hours notice or less, or if I miss an appointment without giving notice. I understand that payment is due at the time of service.
I Agree
Submit
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