Pregnancy Massage Consultation Form

Name

Address

Date of Birth

Telephone Number

Email Address

Occupation

Emergency Contact Details

G.P. Name, Address & Telephone Number

Any Known Allergies?

Are you currently on any medication? If yes, which ones?

Expected Delivery Date

Have you had any of these health problems during your pregnancy past or present? Have you had any of these health problems during your pregnancy past or present? Anemia Breathlessness Vaginal Bleeding Leaking Amniotic Fluid Abdominal Cramping Oedema/Swelling Fatigue Headaches Insomnia Leg Cramps Miscarriage Heartburn Nausea/Morning Sickness Constipation Pre-Eclampsia Pre-Term Labour High/Low Blood Pressure Diarrhea/Vomiting Heart Conditions/Stroke Depression/Anxiety Disorders/Mood Swings Diabetes (Gestational or Mellitus) Skin Disorders/Athletes Foot Epilepsy Blood Disorders Asthma Thrombosis/Phlebitis Sciatica Previous Caesarean Birth Carpul Tunnel Syndrome Bladder Infection

Have you experienced any traumatic accidents, chronic illness, cancer or recent operations? If so please explain

Please list & explain any other conditions or symptoms you have at present, or have experienced, that are not mentioned above

Midwife Name and Telephone Number

Please let us know if this is your 1st, 2nd,3rd or more pregnancy

Please let us know if this is your 1st, 2nd,3rd or more birth

How many weeks pregnant are you and in which trimester?

According to my midwife/doctor I am a low risk/high risk pregnancy According to my midwife/doctor I am a low risk/high risk pregnancy Low Risk High Risk

May I have permission to contact your midwife if required? May I have permission to contact your midwife if required? Yes No

Client Decleration Client Decleration If I develop or are currently experiencing any of the above highlighted conditions/symptoms, I will discuss with my massage therapist and Midwife/GP and obtain consent if required, before continuing any massage treatment.

Client Decleration Client Decleration I declare that the information I have given is correct to the best of my knowledge and I have not withheld any information relevant to the treatment. I have been fully informed about the nature of the treatment I am receiving and the after effects, I may experience. I am willing to proceed with the treatments.

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