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https://static.wixstatic.com/media/7cafce_370971e2a0bb42209a67f25a5bf4c7e3%7Emv2.png Reiki Master Teacher Reiki courses CNHC Reiki practitioner Animal Reiki Natural Lift facial Shiatsu massage Womb massage Pregnancy massage Meditation https://static.wixstatic.com/media/7cafce_0cad100b82ad4ea6ab98aa8cd06c9121~mv2.png Pregnancy & Post-Natal Massage Client Form Pregnancy/Post-Natal Massage: Medical & Consent Form * First name * Last name * Date of Birth 年 月 月 日 * Address * Phone Email * Emergency Contact: Name & relationship to you * Emergency Contact: Phone number (for us to phone/text) How did you hear about ReikiEma? Google Search Other Website Search Recommendation/Word of Mouth Social Media Other 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? Past Complementary Therapies/Massage If yes, what type of therapy, and (approximately) when was your last treatment? Other therapies * 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. Medications info * 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? Exercise info 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? Serious or chronic illness, surgery or traumatic accidents * Pre-natal Care Provider Pre-natal Care Provider info May I have permission to contact your Care Provider? * Due Date 年 月 月 日 * This is my (number: 1st, 2nd etc) Pregnancy Pregnancy Number * This will be my (number: 1st, 2nd...) birth. Birth number * Please tick current problems. Anaemia Leaking Amniotic Fluid, or Vaginal Bleeding * Bladder infection * Uterine bleeding * Blood clot or phlebitis * Chronic hypertension * Abdominal Cramping * Diabetes (gestational or mellitus) Oedema/swelling Fatigue Headaches Insomnia High Blood Pressure * Leg cramps Miscarriage * Heartburn Nausea Problems with placenta * Pre-term labour * Pre-eclampsia (toxemia) * Sciatica Separation of the rectus muscles Separation of the symphysis pubis Skin disorders / athlete's foot Excess thirst Varicose Veins Visual disturbances * Previous caesarian birth Contagious conditions Muscle sprain/strain Heart attack/stroke Constipation Carpal Tunnel Syndrome Low Blood Pressure Morning sickness Anxiety, stress or mood swings Breathlessness Other conditions or problems in current or past pregnancy (please detail below) Anything else you would like me to know? (please detail below) Current pregnancy conditions and symptoms * Please tick any problems experienced in previous pregnancy(ies) Anaemia Leaking Amniotic Fluid, or Vaginal Bleeding Bladder infection Uterine bleeding Blood clot or phlebitis Chronic hypertension Abdominal Cramping Diabetes (gestational or mellitus) Oedema/swelling Fatigue Headaches Insomnia High Blood Pressure Leg cramps Miscarriage Heartburn Nausea Problems with placenta Pre-term labour Pre-eclampsia (toxemia) Sciatica Separation of the rectus muscles Separation of the symphysis pubis Skin disorders / athlete's foot Excess thirst Varicose Veins Visual disturbances Previous caesarian birth Contagious conditions Muscle sprain/strain Heart attack/stroke Constipation Carpal Tunnel Syndrome Low Blood Pressure Morning sickness Anxiety, stress or mood swings Breathlessness Other conditions or problems in current or past pregnancy (please detail below) Anything else you would like me to know? (please detail below) Previous pregnancy conditions and symptoms Further details on current/past pregnancy conditions/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. * Client Signature ボックス内に署名するか、キーボードを使用して入力してください。 署名項目が空です。 クリア Date 年 月 月 日 Submit