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Prenatal Massage and Intake Form

The purpose of this massage intake form is to gather critical client information for safety, to personalize the massage, and to meet legal and professional requirements.

Name

Please fill out this field.

Number

Please enter a phone number.

Please enter a valid email address.

How many weeks pregnant are you?

Please fill out this field.

Is your pregnancy high-risk?

Yes

Are you currently taking any medications or receiving treatment that may affect your massage session?

Yes

Has your healthcare provider given you any restrictions regarding massage, physical activity, or positioning?

Yes

Please fill out this field.

Is there a particular area of the body where you are experiencing stiffness, tension, pain or other discomfort

Head

Neck

Shoulders

Back

Legs

Hands

Feet

All the above

Preferred Appointment Date

Physician Consent (Recommended)

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