Prenatal massage health form | Nest + Nurture Doula Services

Prenatal Massage Health Form

Please complete the form to the best of your knowledge and be assured that it will be treated in the strictest confidence. The questionnaire is designed to make sure that you can practice safely. If there is anything you are unsure about or would like to chat through, please get in touch.

Before you fill out this questionnaire and send the form back to Nurtured Soul, we advise you read the privacy policy so you understand and accept what happens to your data. By you forwarding the questionnaire on to us, we will assume you accept the privacy policies stated

First name

Last name

Email

Phone

Birthday

Month

Day

Year

Address

Occupation

Yes, subscribe me to your newsletter.

Emergency Contact

Relationship to you

Phone

Are you taking any medications?

Yes

No

If yes please list?

Any allergies? (oils, lotions, nuts, fruits, skin, etc.)

Yes

No

If yes please list?

Are you you currently under medical supervision or receiving other medical interventions?

Yes

No

If yes, please describe?

Recent injuries or medical procedures in the past 2 years?

Yes

No

If yes please describe?

Please describe any health conditions you may have:

How many weeks pregnant are you?

When are you due?

Do you know the baby's gender? Don’t feel obliged to tell me, it just helps me know how to refer to them

Is this your first pregnancy?

Yes

No

Do you have other children? (How many/age's)

Have you had any miscarriages? (Details)

Is this an assisted pregnancy (IVF)? (Details)

Have you had problems with previous pregnancies or births?

Have you had any problems with the pregnancy so far?

Is midwife happy with how it’s going? Please provide details of any concerns they may have and details of any scans or tests you have had.

Are you getting any “typical” pregnancy issues? (e.g. swollen ankles, varicose veins, groin pain, back pain, digestive problems)

How are you feeling about it all? (e.g. stress, tiredness, emotional support)

Are there any specific issues you’d like the treatment to help? If, so please give me as much detail as possible.

Is there anything else that you feel I should know?

Have you had professional massage before?

Yes

No

If yes how recently?

Declaration

Please tick if you agree with this statement

I confirm that the information provided on this form is accurate to the best of my knowledge. I understand the nature and purpose of prenatal massage therapy. I agree to inform my therapist of any changes to my health, pregnancy status, medications & care

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