Spa Materna Intake Form for pregnant Women

We want to create a very pleasant and comfortable massage experience for you. By completing the form below, you will assist us in creating the ultimate massage experience for you. The information you provide on this form will be kept private and confidential. Please complete the following form, print it out and bring it with you to your About Us.
Name:
DOB:
Address:
Phone:
Emergency Contact
Name:
Phone:
Relation:
Email:
Would you like to receive our newsletter?
Physician/Midwife's Name:
How did you hear about Spa Materna?
F
If applicable, name of person that referred you
How many massages have you had prior to today?
None 1

Please check all symptoms that apply to you below. This information is completely confidential and important in customizing your treatment. It will only be shared with your written permission.

Column 1

*Column 2*

*Column 3*
Allergies Pre-pregnancy        Diabetes Gestational Diabetes
Arthritis Heart Problem Threatened         Miscarriage
Bruise easily High Blood Pressure Early Labor
Asthma Thyroid disorder Placental dysfunction
Dislocations or         Fractures Rh Negative Anemia
Numbness or         tingling
Previous Pregnancy        Complication
Fetal development         complication
Pulled muscle Genetic Disorder Pre-eclampsia
Back/Neck Injury Multiple pregnancy Eclampsia
Recent Surgery Drug/Alcohol use Toxemia
Migraines Kidney/Liver disorder Blood clots
Cancer Seizures Bleeding/cramping
Varicose veins Blood disorder Amniotic fluid leakage
Sciatica Lupus  
Skin irritation    
Open wound    
Nausea    
Swelling    
Hemorrhoids    
Leg cramps    

*Checks in columns two or three require a Healthcare Provider's Release form. Please print the form and bring the signed release form to your initial appointment. You can print a blank form from our website or ask your healthcare provider to do so. Blank forms also available at our office.

Is this your first pregnancy?
When is your due date?
Is this your first pregnancy massage?

Please list any medications you are currently taking along with the reason it is prescribed.

What areas would you like the massage therapist to focus on during a massage?


Are there any areas you want your therapist to avoid?

What kind of pressure do you prefer on a scale of 1 to 10?
1=Very light 10=Very firm

We strive to treat you as an individual. We want your treatment to be customized to your likes and dislikes. Is there anything else about you or your body that you want to share with us?

Your comfort and safety, and the safety of your baby, are of the utmost concern at all times during your treatment. It is your responsibility to request changes in pressure, speed or any other variables in your treatment. Massage therapy is not a substitute for medical treatment. Massage therapists do not diagnose illness or disease or prescribe medication.

Please indicate your understanding of the above/below and give informed consent by initialing the statements below and signing your name.

Because therapeutic massage should not be performed under certain circumstances, I affirm that I have checked off all medical conditions of which I am aware.

 

I will inform my practitioner of any changes in my medical status.

 

I have not withheld any information that may be relevant to my treatment.

 

If I experience any pain or discomfort during my treatment, I will immediately inform my practitioner.

 

I forever release Spa Materna,LLC, its director and employees from all liability for any injury or damage which may occur as a result of the treatment rendered.




Please print this page, then sign and date it below:
Signature: __________________________________
Date: ______________________

 

Swedish Massage
(828) 254-2222
Call today to schedule your appointment!