Prenatal Massage Intake Form

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Required for expectant mothers before a prenatal massage session to ensure your comfort and safety.

First and last name

How far along are you?*

When is your due date?*

Do you have any of the following?*

Vaginal bleeding/spotting

Severe cramping, or abdominal/pelvic pain

High blood pressure/preeclampsia

History of miscarriages or preterm labor

Blood Clots/DVT

Gestational diabetes

Severe swelling, headaches, dizziness or vision changes

Placenta previa/placenta issues (If known)

Other

None of the above

If yes/other, please explain

Please tell me what position you are most comfortable in:*

Type full name as signature

Signature Date*

Month

Day

Year

I agree this is my electronic signature. All the information is up to date and accurate to my knowlegdge

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