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Remedial Pregnancy Massage Confidential Case History Form
Please take a moment to fill out this confidential health history form. This will ensure that you receive proper treatment and that it is safe for you to do so.
Name (please print): Date:
Email:
Address: Postal Code:
Phone: Mobile Home Business
Date of Birth: _____/______/_______ Health benefit fund:
Occupation: Does your job require you to sit / stand for long periods of time? N / Y
Sporting and recreational activities:
How did you hear about this clinic?
Have you had any complications or during your current/previous pregnancy? N / Y
Which trimester are you in?: 1st 2nd 3rd Due Date: Birth location:
Is this your first pregnancy? N / Y , if no how many previous pregnancies:
Do you experience Brackson Hicks? N / Y , if yes how many weeks did they commence at?
Are you currently experiencing nausea or morning sickness? N / Y Is your baby engaged? N / Y
Have you ever received massage while pregnant before? N / Y
Massage pressure preference: 1 2 3 4 5 6 7 8 9 10
Please circle a number: Very Gentle Relaxing Firm Deep Tissue Very Deep Tissue
What is you primary complaint
(Please indicate on chart)
Can you describe it? DULL/ SHARP/ SHOOTING/ ACHY/ NUMB/ TINGLING/ STIFF
Pain scale: (low) 1--------5--------10 (high)
Does it radiate anywhere?
Does anything aggravate your symptoms?
This condition interferes with: Work / Sleep / Daily Routine / Activities / None
Have you seen any other health care practitioner concerning this complaint? N / Y
Medical Dr. Massage Therapist Acupuncturist
Chiropractor Physiotherapist Naturopath
Other
Have they provided comfort or results?
Current medication:
Western: Conditions used for:
Homeopathic and Herbal: Conditions used for:
Do you have any allergies to oils, ointments or creams that could be used during treatment? N / Y
Car / Sporting/ or accidental Traumas: Experienced at any stage of life Y / N Years since incident
Did you experience whiplash? Y / N do you experience headaches? Y / N
Did you receive any treatments? Y / N
If motor related, were you hit from the side or behind?
Do you have any internal pins/wires/artificial joints?
Surgery/injuries/hospitalization: (date, past & current symptoms)
Life style: Smoker: Yes No Previously Diet: Poor Average Good Hydration per day: 2 Glasses 5 Glasses 8+ Glasses Caffeine intake per day: 1 serves 3 serves 5+ serves Please check all that apply. leg cramps bladder infection blood clot or phlebitis hypertension
oedema/swelling abdominal cramping hypo or hyperglycaemia twins or more
insomnia varicose veins skin disorders ache
high blood pressure muscle sprain/strain leaking amniotic fluid heart attack/stroke
low blood pressure nausea athletes foot bursitis
sciatica anaemia preeclampsia (toxaemia) allergy to nut oils
miscarriage carpal tunnel
syndrome
pre-‐term labour arthritis
fatigue Hip pain contagious conditions visual disturbances
headaches Lower back pain problems with placenta uterine bleeding
previous caesarean
birth
separation of the
symphysis pubis
separation of the rectus
muscles
diabetes (gestational
or mellitus)
Other conditions or problems in current or past pregnancies I acknowledge the above information as being true to the best of my knowledge and agree that all information is confidential.
Signature: Date:
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