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):
    Address:
    Occupation:
    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
    Address:
    4. Pregnancy History
    Partners Name:
    Previous Pregnancies:
    Miscarriages:
    Other:
    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
     
    Other?:
    6. Previous Antenatal Check-Up Details
    Date of Checkup (DD MMM YYYY):
    Blood Pressure Reading:
    Bleeding:
    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? :
    In the Captcha Input Box please enter the code displayed here:      captcha
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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.
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