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: