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Prenatal Massage Intake Form

First name*

Last name*

Email*

Phone

Emergency Contact:

How did you hear about me?

When is your Due Date?

Month

Day

Year

Have you experienced any of the following during this pregnancy or in past pregnancies?

Swelling

Headaches

Carpal Tunnel Syndrome

Lower Back/Sacral Pain

Varicose Veins

High Blood Pressure

Gestational Diabetes

Other

Please list any medical conditons, surgeries or injuries

Do you have any allergies or sensitivities? (ie. fragrances, nut oils)

What type of pressure do you like?

Any special preferences or (ie. likes/dislikes, no music, minimal talking, etc)

Any places you want me to avoid? (ie. feet, face, scalp)

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