Name
*
First Name
Last Name
preferred name
Email
*
Birthday
MM
DD
YYYY
Phone
*
(###)
###
####
Emergency Contact Name + Phone Number
How many weeks are you in your current pregnancy?
*
Is this your first pregnancy?
*
Have you had prenatal massage before? If yes, what was it like?
*
Is your pregnancy considered high risk or low risk?
*
High Risk
Low Risk
Besides going through pregnancy, what does your body endure regularly?
*
(i.e. occupation, physical practice, leisure activities, sleep, self care)
Are you taking any medication?
(If yes, please list below)
Are you currently immunocompromised?
Have you ever tested positive for COVID-19? If so, please describe any ongoing effects the virus has had on your body
(ex: cardiovascular, bruising, fatigue, respiratory, etc.)
Massage therapy during pregnancy has been shown to be beneficial for a number of common complaints such as fatigue, musculoskeletal pain, sciatica, edema, and many others. However, there are risks associated with specific conditions that may occur during pregnancy. You must inform your massage therapist if you have or have had in the past any of the following conditions or symptoms which may make massage therapy during pregnancy contraindicated, or may require your therapist to alter the massage.
Any diagnosed conditions?
Please share any major medical history with approximate dates.
*
(i.e. surgeries, physical/mental/emotional trauma, broken bones, chronic conditions)
Do you have any questions or concerns about receiving massage? If so, please explain.
If you are neurodivergent (or even if you aren't) are there any aspects of the session or preferences that you want to communicate about specifically? (example: level of pressure, scents, use of oil, lighting, particular words or phrases to use or avoid?)
Do you have a history of trauma? Is there anything you'd like your therapist to be aware of?
Do you have any psychological conditions or mental health concerns you'd like your therapist to be aware of?
Are there any areas of the body you'd like your therapist to avoid completely?
Please feel free to use this space to add any relevant details that I should know.
(i.e. present symptoms, duration of symptoms, what makes them better/worse, quality of discomfort/sensation, previous bodywork or energy work experience, etc)
How did you come to find out about the practice?
*
Instagram
Facebook
Mutual Friend(s), feel free to mention their name if you feel comfortable!
Lex
Dance community
Google Search
Other
Queer Healers
If you selected mutual friend(s) or other, please specify below.
Is there anything else you would like me to know before working together?
