Pre & Post Natal Consultation Form

To ensure we provide you with the best possible care, it’s important that you answer the following questions as thoroughly as possible. The more detailed your responses, the more we can tailor your treatment to suit your individual needs.

Please remember, injuries or surgeries from years ago can still impact your body today due to scar tissue and compensation patterns. The body is incredibly adaptable, and while it learns to function under the circumstances it's faced with, this doesn't mean you have to continue living with the tension and aches you may be experiencing.

First Name

Last Name

Preferred Name

Email

Phone

Address

Country/Region

Address

City

Zip / Postal code

About You

Have you had a pregnancy massage before?

Yes

No

Have you had any operations/injuries (past or present please specify)

What do you do for work?

What do you enjoy doing in your free time (exercise and activities)

Areas of tension/pain you are experiencing (past and present helps)

Any other additional information you would like to share, please write it here:

Health Details

Please provide further details if you ticked any of the boxes above

Areas to avoid in the massage session?

GP Practice Name

Emergency Contact Name

Emergency Contact Number

How many weeks pregnant are you?

When is your due date?

Have you had a pregnancy before?

Yes

No

Prefer not to answer

Are there any concerns from your last midwife scan/review?

Yes

No

Is this considered a high risk pregnancy?

Yes

No

Please give more details if you ticked any of the above

Belly Baby massage is a wonderful and gentle way to deepen your connection with baby whilst you have a massage. Is this something you want in your session?

Yes

No

I'd like to hear more about it on the day

Signature

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Treatment and Disclaimer

By signing and submitting this form, you acknowledge that:

The therapist reserves the right to withhold or modify a treatment if it is deemed unsuitable or potentially harmful to your health.