Client's Info | Therapeutic Relaxa

Pregnancy Massage Client's Intake From

First Name

Last Name

Birthday

Street Address

Street Address Line 2

City

Province

Postal code

Phone

Emergency Contact

Ob/Gyn/Midwife handling your care

Due Date? How many weeks postpartum?

Do you have any complications or medical issues with your pregnancy? If Yes, please explain.

Do you have any changes in veins? N/Y. If Yes, where?

Have you been pregnant before? N/Y. If Yes, how many times?

Types of births you have had in the past: cesarean / vaginal / hospital / home / birthing center

Do you have any swelling (Yes/No/Sometimes)

Will you be attempting a V-BAC (vaginal birth after cesarean)?

Please describe anything you’d like to address in the session today, and/or any areas of concern:

Any sypmtoms? (Vaginal Bleeding, Fever, Flu, Acute illness, Decreased fetal movement over a 24 hour period, Diarrhea, Pain in the abdomen that is new and unexplained, Pregnancy Induced Hypertension (PIH), Any pitting edema, A history of miscarriage or pregnancy complications, twins, Premature rupture of the membranes or history of that, Diagnosed incompetent cervix, Deep Vein Thrombosis, etc.)

Consent for Pregnancy Massage with Therapeutic and Relaxation Massage Clinic

I have read this entire form including the contraindications listed above. I attest that I have none of the above conditions, nor do I have any medical problems whatsoever. I am in general good health. I am aware that I am being massaged by. I agree to hold my massage therapist and Massage Therapy Connections harmless in the event of any medical/health problem being experienced by me during or after the massage. I have read and I understand what has been stated above. I have answered all questions and have supplied personal information honestly and accurately. I realize that if I have been dishonest I could be endangering my or my unborn child’s health.

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Your Signature

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Minor Consent From

Minors are permitted to receive massage in the clinic.

Parents or legal guardians must be present in helping complete the Health History Form for the minor, along with consent for the massage therapy session.

Guidelines:

All minor clients under the age 18 can only receive massage with written parental/legal guardian consent.
parental/legal guardian should be in the treatment room during each session.
In collaboration with the consenting adult and child, the massage therapist will assist in establishing goals for the session.
Appropriate draping will be always used during the massage, only areas being massaged are uncovered.

I,

am the parental/legal guardian of,

I have read the above information and give permission for my child,

To receive massage therapy from