Pregnancy/Post-Natal Massage: Medical & Consent Form

First name

Last name

Date of Birth

Address

Phone

Email

Emergency Contact: Name & relationship to you

Emergency Contact: Phone number (for us to phone/text)

How did you hear about ReikiEma?

Yes, subscribe me to your newsletter.

Have you received Massage Therapy or Bodywork before (including before pregnancy)?

Yes

No

Medical Details

GP Address

GP Surgery Phone number

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

If yes, what type of therapy, and (approximately) when was your last treatment?

Are you currently taking any Medication?

Yes - prescribed

Yes - not prescribed

No

If you are taking any medications, please specify the name if you can, and what it's for.

Do you exercise?

Yes

No

If you answered "yes" to the previous question, how many times per week, for how long, and what type(s) of exercise?

Please list and briefly describe any conditions or symptoms you have experienced, or are experiencing.

Any allergies or sensitivities

Have you had any serious or chronic illness, operations or traumatic accidents?