Prenatal Intake Form

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2110 Eagle Creek Lane, Suite 100

Woodbury, MN 55129

651-379-4004

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Please fill out our electronic prenatal intake form prior to your Prenatal massage and click submit when complete. Thank you!

BODY RHYTHMS MASSAGE

Prenatal Intake Form

Full Name

Date of Birth

Have you had a professional massage before?

Yes

If yes, date of last treatment:

How many weeks pregnant are you currently?

Total number of pregnancies experienced? Number of births?

Due Date:

Are you regularly seeing a physician, nurse midwife, or midwife?

Yes

Do you have any medical concerns? If so, please list:

Any recent injuries or surgeries? If so, please list:

Are you currently taking any medications? If yes, please list name and use:

What exercise activities do you participate in?

Please indicate any of the following that apply to you:

Have experienced preterm labor or miscarriage

Pregnancy considered to be high risk

Morning sickness, vomiting, diarrhea, or fever

Reduction in fetal movement in the past 24 hours

Excessive swelling in arms, legs, hands, or feet

Poor circulation in legs (Deep Vein Thrombosis)

Inactive or placed on bed rest

Abnormal bleeding/discharge in the last 24 hours

Placenta Previa

Placenta Abrupto

Gestational Diabetes

Renal Disease

Cardiovascular Disease

Systemic Lupus

Preeclampsia/Eclampsia

None of the Above

Explain any conditions you have marked above:

Are there any other conditions not listed above that pertain to you?

Do you have any allergies or sensitivities? If so, please explain:

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 during my pregnancy, if any.

Your Signature

Thanks for submitting!

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