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Stephanie Norquay – Birth Support Services – With you… through pregnancy, childbirth & early parenting.

Pregnancy Massage Client Questionnaire

In order to expedite your administration process associated with massage therapy services, I have provided an electronic ‘Questionnaire Form‘.

I would appreciate it if you could complete this form online. The information will allow me to start planning your massage in advance.

1. General Information
Referred by:
First Name
Last Name
Email Address
Phone Number
Date of Birth (DD MMM YYYY):
Weeks Pregnant:
Home/Hospital/Birth Centre:
Est. Due Date (DD MM YYYY):

2. Primary Caregiver
Primary Caregiver:
Contact Ph:

3. Emergency Contact
Emergency Contact:
Contact Ph:
Email Address

4. Pregnancy History
Partners Name:
Previous Pregnancies:
Name and age of other children (Please include length of gestation):
Previous Labour/Birth Details:
Postpartum recovery after last pregnancy & birth:
Previous pregnancies - Any complications/discomforts and treatments received:
Previous experience with pregnancy massage:
Other practitioners / treatments currently receiving (Acupuncture, Osteopathy, Massage Therapy, Naturopathy, etc.):
Prenatal Testing (GBS, Blood Glucose, Ultrasound, Amniocentesis, etc):
Any medications/prenatal supplements currently taking?:

5. Medical History
Do you suffer from any of the following?:
Heart/Blood circulation disorders     YesNo
Spinal Disorders     YesNo
Sciatica/Gluteal Pain     YesNo
Hip Pain     YesNo
Illness     YesNo
Separation of Symphysis Pubis     YesNo
Injuries     YesNo
Separation of Abdominal Muscles     YesNo
surgeries     YesNo
Leg Cramps     YesNo
Accidents     YesNo
Carpal Tunnel     YesNo
Osteoporosis/Arthritis     YesNo
Nausea     YesNo
Varicose Veins     YesNo
High Blood Pressure     YesNo
Allergies/Skin Problems     YesNo
Oedema/Swelling     YesNo
Diabetes     YesNo
Pain/Numbness     YesNo
Preterm Labour     YesNo
Bladder Infection     YesNo
Abdominal Cramping     YesNo
Uterine Bleeding     YesNo
Preeclampsia     YesNo
Chronic Hypertension     YesNo
2 or more consecutive miscarriages     YesNo
Blood Clot or Thrombophlebitis     YesNo

6. Previous Antenatal Check-Up Details
Date of Checkup (DD MMM YYYY):
Blood Pressure Reading:
Foetal Movement:
Any changes or concerns?:
Any further comments?:

7. Additional Information
What do you do on a regular basis to stay healthy? (physically/mentally/emotionally):
How has your pregnancy been so far? ::
Primary reason for appointment and/or areas of discomfort or concern :
Is there anything else you would like to share with me? :

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Privacy Policy – I collect the information set out above in order to provide you with massage therapy services. I will keep your information secure and confidential.