Intuitive Bodywork LLC
Prenatal Massage & Bodywork Addendum
Intuitive Bodywork Massage Therapy. If you are pregnant, please complete this form in addition to the Confidential Client Intake form.
Your Email Address
Name Of Your Prenatal Care Physician Or Midwife
Physician Or Midwife Phone Number
May We Have Permission To Contact Your Prenatal Health Care Provider, If Needed?
My Due Date Is
Number Of Weeks Pregnant
Number Of Previous Pregnancies
Number Of Previous Deliveries
According To My Doctor Or Midwife, I Am Experiencing A
Low Risk Pregnancy
High Risk Pregnancy
Do Not Know
Please Check Any Current Or Prior Pregnancy Related Conditions
Separated Rectus Muscles
Separation Of Symphysis Pubis
Carpal Tunnel Syndrome
No Current Or Prior Conditions Related To Pregnancy
Please Describe Your Pain Including Location(s) Of Pain & Severity
Any Other Current Or Prior Pregnancy Related Conditions?
If I am currently having or develop any complications during my pregnancy, I will discuss the condition with my massage therapist, and will have a medical release for massage therapy signed by my prenatal care provider before continuing massage. I will immediately let my therapist know of any pain or discomfort so that pressure and strokes can be adjusted to my level of comfort.
I have completed this health form to the best of my knowledge. I understand that massage therapy is a health aid and does not take the place of a physician’s care. Any information exchanged during a massage or bodywork session is confidential and is only used to provide you with the best health care services. I know that massage/bodywork can be harmful in some circumstances; I fully assume responsibility for receipt of massage therapy, and release and discharge the therapist from any and all claims, liabilities, damages, actions from therapy received. I fully and fairly answered these questions and described my health and will tell the practitioner of any changes.
I Understand And Agree To The Above Statements And Conditions
Electronic Signature. Check The Box Above. Type Your Name Here And Enter Today's Date Below. NOTE: Your Name On This Line Is Your Electronic Signature.
Do Not Fill This Out