Have you recently had any surgery? YesNo
Do you now or have you ever smoked? YesNo
Do you have any known allergies? YesNo
Which trimester are you in? 1234 (postpartum)
How many pregnancies have you had in total?
Do you have pain/soreness in a particular area? YesNo
Please tick the box if any apply & give details:
Over 36Gestational diabetesPlacental dysfunctionBlood clots/phlebitisVaricose veinsHeartburnCurrent infection/contagious diseaseBruise easily or bleeding disorderAbdominal cramping, miscarriagesFirst pregnancyFrequent headaches/migrainesSwollen feet or handsHigh blood pressureSuffer from epilepsy or seizuresBladder/kidney infectionMuscle crampsUterine bleedingPre eclampsia (toxaemia)
Prenatal massage therapy client release form
I have read, understood and have completed this consultation to the best of my knowledge. I have discussed with my physician & had the opportunity to speak to both practitioners about the information listed above. Yes
I confirm that:
*I have not experienced any of the complications listed above, which would make it unwise to have massage therapy
*I have not experienced any of the conditions listed, which would make it unwise to have massage therapy
*I am experiencing a low-risk pregnancy
*I am receiving medical care including regular check-ups throughout my pregnancy
I understand:
*that the massage I receive is for the purpose of stress reduction.
*that the massage therapist does not prescribe medical treatment, pharmaceuticals, nor do they perform spinal manipulations
*that it is you the client responsibility to inform of any changes to this information
*that if I experience any pain or discomfort I will inform the therapist immediately so the pressure can be adjusted
By signing this release I hereby waive Danielle Cuglietta from all liability past, present and future to massage & bodywork
I have read, understood and have completed this consultation to the best of my knowledge. I have discussed with my physician & had the opportunity to speak to both practitioners about the information listed above. Yes
Aftercare
Leave your jewellery at home, remove your contact lenses and bring your glasses for your return journey, rest or nap if necessary, drink plenty of water to help remove lymph and toxins.
I have read, understood and agree with the before/after care instructions: Yes