Supportive Fertility Massage Intake Form

2110 Eagle Creek Lane, Suite 100

Woodbury, MN 55129

651-379-4004

BODY RHYTHMS MASSAGE

Supportive Fertility Massage Intake Form

Full Name

Date of Birth

Occupation

Number of pregnancies experienced?

Number of miscarriages experienced?

Number of births experienced?

Are you seeing a Fertility Specialist?

Yes

If yes, name of doctor:

Have you experienced a professional therapeutic massage before?

Yes

Are you actively trying to conceive?

Yes

If yes, how long have you been trying?

Are you currently taking any medications, including herbal? Please list medications:

Do you currently have any areas of discomfort?

Yes

Please list areas of discomfort:

Any past injuries or surgeries?

Yes

If yes, please list/explain:

What is your level of open-mindedness?

Is your partner open to receiving therapeutic massage?

Yes

Maybe

Date of last menstruation:

If actively trying to conceive, appointments need to be between menses and ovulation. Fertility Massage will not be performed upon ovulation through menstruation.

Are your cycles regular/predictable?

Yes

Sometimes

Do you know when you ovulate?

Yes

Sometimes

Are you tracking your ovulation?

Yes

Sometimes

Do you have pain while ovulating?

Yes

Sometimes

How is your diet? Your partner's diet? Any consultation with a nutritionist?

Explain:

Because massage/bodywork should not be performed under certain medical conditions, please make sure you have stated all known medical conditions and answered all questions honestly.

Please note: Body Rhythms Massage does not treat or prescribe within the context of your massage therapy session. Also, going through the process of Fertility Massage does not guarantee a successfully conceived pregnancy and Body Rhythms Massage does not promote this modality as such. Fertility Massage is a supportive massage technique designed to enhance the conception process.

I have read the Client Bill of Rights (below) and I understand I have full opportunity to ask any questions I have about this document and my rights as a client. I have completely read and answered all the questions above to the best of my knowledge and will notify my massage therapist of any future health changes, if any.

Your Signature

Thanks for submitting!