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Pregnancy & Post-Natal Massage
Client Form

Pregnancy/Post-Natal Massage: Medical & Consent Form

Date of Birth
Day
Month
Year
How did you hear about ReikiEma?
Have you received Massage Therapy or Bodywork before (including before pregnancy)?
Yes
No

Medical Details

Have you received Massage Therapy or any other Complementary or Holistic Therapies before?

Past Complementary Therapies/Massage

Other therapies

Are you currently taking any Medication?

Medications info

Do you exercise?
Yes
No

Exercise info

Serious or chronic illness, surgery or traumatic accidents

Pre-natal Care Provider info

May I have permission to contact your Care Provider?
Due Date
Day
Month
Year

Pregnancy Number

Birth number

Please tick current problems.

Current pregnancy conditions and symptoms

Please tick any problems experienced in previous pregnancy(ies)

Previous pregnancy conditions and symptoms

Further details on pregnancy conditions/symptoms

I am experiencing a low risk/high risk pregnancy, according to my doctor/midwife.

Disclaimer / Client Statement


For my records, I need to confirm that you have read, understood and answered all of the previous questions. If there is anything you do not understand, or wish to ask about, please ask me now (before signing this statement).

 

Otherwise, please read the following statement, and sign below to show that you agree.

 

To the best of my knowledge, the information I have given in this form is true, and I have not withheld any information concerning my health.

I will keep Ema Melanaphy updated on my health, should there be any changes to the answers already given.


If I have, or develop any medical complications (marked with * in the list above) I will discuss the condition with my massage therapist, and will get a medical release signed by my pre-natal care provider, before continuing bodywork.

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Date
Day
Month
Year

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Ema Melanaphy is a qualified professional Reiki Practitioner CNHC Registrant (the UK Government's voluntary regulator for Complementary Therapists), a Reiki Master Teacher member of the UK Reiki Federation, and is accredited by the Reiki Federation as a professional Animal Reiki Practitioner. Ema has been a professional Reiki practitioner since January 2020, and is a qualified practitioner of Reiki, Animal Reiki, Pregnancy Massage, "Natural Lift" Rejuvenation Facial Massage, Holistic Acupressure, and also a Student Practitioner of Zen Shiatsu. Ema is a Certified professional Therapeutic Meditation Teacher, and a certified Independent Reiki Master Teacher of Usui Shiki Ryoho and Usui Reiki Ryoho, since 2021.

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Complementary and Natural Healthcare Council logo - links to CNHC website listing for Ema Melanaphy. Text reads "CNHC Registered
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"professional (TM) standards Authority accredited register" with the psa logo, in the bottom half of the box.
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Reiki Medic-Care logo: link opens official Reiki Medic-Care website

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