Prenatal Massage Information Form (Download this form as a pdf file here)
This form must be submitted 24 hours prior to your session to ensure there are no contraindications that may need further discussion or a doctor’s clearance.
Name:______________________________________________________Date:_________________
Address: __________________________________________________________________________
Phone Number: ______________________ Email: _________________________________________
Before you receive bodywork, please answer the following questions:
What is your Estimated Due Date (EDD)? ___________ Who is your doctor? ____________________
Do you have Diabetes? Yes / No Is it gestational? Yes / No
Have you had surgery within the last 30 – 60 days? Yes / No
If yes, for what? __________________________________________________________________
Do you have any old or new back injuries unrelated to this pregnancy? (i.e., car accident, etc.)
_________________________________________________________________________________
Do you have any type of heart conditions?
_________________________________________________________________________________
Are you currently taking any medication for depression?
_________________________________________________________________________________
Are there specific things you would like addressed in this session?
Sciatic Pain / Stretch Marks / Headaches / Low Back Pain / Upper Back Pain / Swelling
Other: _____________________________________________________________________
Do you prefer light, moderate, hard-deep pressure during your massage? (circle one)
Do you prefer silence (no talking) during your massage? YES / NO
Is it okay to get oil in your hair and on your face? (for cranial work) YES / NO
Do you have any allergies? (i.e., Eucalyptus or Menthol) YES / NO
Would you like to be placed on a mailing list to receive updated massage information, special offers, etc. via email? YES / NO
I understand that should my condition change in any way I am responsible for notifying my practitioner immediately and I am aware that I may need a doctor’s clearance before my practitioner can work with me because of the change in my condition.
Signature: _______________________________________________ Date: _____________________
