Name *

First Name

Last Name

Phone *

(###)

###

####

Emergency Contact Phone *

(###)

###

####

Can we speak with this contact regarding your pregnancy in cases of emergency? *

Yes

No

Prenatal Care Provider Phone

(###)

###

####

Please check any current or previous conditions, experiences, or issues

Please inform me at every session if there are changes to current conditions or if new ones arise

Anemia

Fibromyalgia

Allergies

Leg cramps

Back Surgery or injury

Low back pain

Spinal Disc Issues

Skin disorders/Athletes Foot

Bladder or kidney infection

Varicose veins

Heartburn

Seizures

Insomnia

Headaches

Carpal Tunnel Syndrome

Separated Pubic Symphysis

Separated Abdominal Muscles

Diabetes (Gestational or Mellitus)

Dizziness

Recent Airplane Travel or Long Car Travel

Cancer

Nausea or Vomiting

Sciatica

Round ligament pain

Previous cesarean birth

Leaking Amniotic Fluid

Visual disturbances

Twins or more

Chronic Hypertension

Placental Issues

High Blood Pressure w/Pregnancy

Abdominal cramping

Preeclampsia

Gestational hypertension

Miscarriage

Bleeding (uterine)

Blood Clot or Blood clotting disorders

Family history of blood clots or disorders

IVF/Fertility Treatment in this pregnancy

Previous high risk pregnancy

Lupus or other autoimmune

Pre-Term labor or birth/abdominal cramping

Any other concerns?

Are you experiencing a high risk pregnancy? *

Yes

No

I confirm that I have answered the questions accurately to my best knowledge. I agree that I will inform my practitioner at the start of every session if there have been changes to my medical history above or develop any new conditions. I consesnt to receive massage therapy in this session and in further sessions. I understand that this is not a substitute for seeing the doctor or my prenatal care provider. I understand that I should inform my practitioner immediately should any aspect of the work during our sessions not feel comfortable. *

Yes

No