Prenatal Health Intake Form

If you are pregnant, please complete the following health intake form prior to your first appointment. You may also need to have your doctor complete and sign our Medical Release and bring it with you to your first appointment. Your information is used only for the purpose of ensuring the safest and most effective massage experience for you, and is held in strictest confidence.

Online Submission

By submitting the following form, you agree to the following:

  • Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile prior to any future sessions and understand that there shall be no liability on the therapist’s part should I fail to do so.
  • I understand I may also be required to have a medical release signed by my health care provider.
  • Cancellation/late arrival policies: No-show or cancellation within 24 hours of a scheduled massage will result in charge of the full price of my intended session. Missed or late cancellation will void my gift certificate if being used for payment. Late arrival will shorten my session accordingly, with the full payment due. (Should you have a medical emergency that prevents you from keeping your scheduled appointment, this policy will be waived.)
  • The therapist also reserves the right to refuse service to anyone for any reason.

[contact-form subject=”SeaRhythms Prenatal Health Intake” to=””] [contact-field label=”Name” type=”name” required=”true” /] [contact-field label=”Email” type=”email” required=”true” /] [contact-field label=”Phone Number” type=”text” required=”true” /] [contact-field label=”Mailing Address” type=”text” required=”true” /] [contact-field label=”Emergency Contact and Phone #” type=”text” required=”true” /] [contact-field label=”Birth Date/ Age” type=”text” required=”true” /] [contact-field label=”In what week of pregnancy are you currently?” type=”text” required=”true” /] [contact-field label=”What number pregnancy is this for you?” type=”text” required=”true” /] [contact-field label=”Are you regularly seeing a physician or midwife for your prenatal care? Please provide name and phone number” type=”text” required=”true” /] [contact-field label=”May we contact your doctor/midwife if necessary?” type=”radio” required=”true” options=”Yes,No” /] [contact-field label=”What discomforts, pain, or other needs are you hoping to have addressed through massage therapy?” type=”textarea” required=”true” /] [contact-field label=”Have you had any complications or problems with this pregnancy? (bleeding, cramping, fluid leakage, swelling, high blood pressure, rapid weight gain, protein in urine, vision disturbances, severe nausea, vomiting, headaches, fetal abnormalities, high blood sugar, other)” type=”textarea” required=”true” /] [contact-field label=”Do you have any medical conditions? (diabetes, heart, liver, kidney, or lung disorders, convulsive disorders, uterine abnormality, connective tissue disease, other)” type=”textarea” required=”true” /] [contact-field label=”Is your pregnancy considered high risk by your health care provider?” type=”radio” required=”true” options=”Yes,No” /] [contact-field label=”Please list all medications and supplements” type=”textarea” required=”true” /] [contact-field label=”Have you had any recent injuries, illness, or accidents?” type=”textarea” required=”true” /] [contact-field label=”Do you have any additional comments related to your pregnancy and health?” type=”textarea” required=”true” /] [contact-field label=”Is this your first massage? If no, when was your last?” type=”text” /] [contact-field label=”Do you have any allergies? Please list.” type=”text” required=”true” /] [contact-field label=”How did you hear about SeaRhythms?” type=”text” /] [/contact-form]

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