Prenatal Intake Form

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 required

Have you had a professional massage before?

Yes

No

If yes, date of last treatment:

How many weeks pregnant are you currently?

Total number of pregnancies experienced? Number of births?

Due Date: required

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

Yes

No

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?

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!