Pregnancy Form

Name*

First NameLast Name

Date of Birth*

DayMonthYear

Address*

Street Address

Street Address Line 2

Town/ City

Post Code

Email*

Phone*

Emergency contact details - name and phone number*

Expected delivery date*

Prenatal care provider / doctor / midwife - name and contact number*

What number pregnancy is this for you? (1st, 2nd, 3rd etc)*

How many weeks pregnant are you? *

Which trimester are you in? Please note massage is only advised after your first trimester.*

First - weeks 1-12Second - weeks 13-26Third - weeks 27+

Are you currently seeing a doctor, specialist or therapist for any other reason?*

NoYes

Please give details

Please list any medications you are taking with details of what condition they are treating.

Have you had any serious or chronic illness, operations or accidents?

** IMPORTANT ** Please let me know if you have, or have every had, any of the following conditions. Please tick all that apply. If you are experiencing any of these please discuss with your prenatal care provider and ask them for their advice and consent prior to booking a massage treatment.*

Please tick any of the following conditions that you have experienced during this pregnancy.

Any other health or medical conditions that haven't been mentioned?

Do you suffer from any un-diagnosed pain? Please give further details.

What are your main reasons for wanting a pregnancy massage treatment?*

Do you exercise?

Never1-2 days3-4 days5+ days

Please give details of any exercise you currently do.

Are you still working?

NoYes

What is your occupation?

Is there anything else you would like me to know?

I am experiencing a low risk / high risk (select one) pregnancy according to my doctor/midwife.*

Low riskHigh risk

If I am currently having or develop any conditions or symptoms highlighted above (*) I will discuss the condition with my massage therapist, and will have a medical consent for massage signed by my prenatal care provider before continuing with massage treatment.

This information I give is true to the best of my knowledge. I understand that massage is a health aid and does not take place of any medical care.

Any information exchanged is confidential and is only used to provide a better health care service.

I confirm agreement to be contacted with information on Massage Therapy by Vicky Griffiths and understand that I have the right to withdraw this ‘consent to be contacted’ at any time.

I confirm that Vicky Griffiths may use the information provided in this form, and any other information that I later provide, for treatment purposes and that this information:

will be used in confidence and stored securely
will not, in any circumstances, be shared with a third party without my written consent
will be retained by Vicky Griffiths for a period of time such as complies with professional, legal and insurance requirements that she must fulfil.

If I am not able to make a scheduled appointment I agree to cancel the appointment 24 hours in advance. If I miss a scheduled appointment without giving 24 hours notice, I agree to pay any missed appointment charge.

Client Signature

Date

Pregnancy Massage - Client Details

Pregnancy Details

Medical Details

About You

Consent