| Client Information
for Pre- and Post-Natal Clients
Name________________________________ Age____ Today’s
Date ___________________
Week of Pregnancy ____________________ Expected Due Date
___________________________
Physician or Midwife ___________________ Doula (if applicable)
_________________________
Emergency contact (name and cell phone) __________________________________________________
____ multiple pregnancy (twins) ____ varicose veins
____ gestational diabetes ____ phlebitis
____ placental dysfunction ____ leg cramps
____ high blood pressure ____ restless legs
____ pre-eclampsia ____ headaches
____ threatened miscarriage ____ headaches
____ premature labor ____ heartburn
____ heart disease ____ constipation
____ bladder infection ____ hemorrhoids
____ swollen hands or feet ____ difficulty sleeping
In which areas of your body are you currently experiencing
tension, discomfort, or pain?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Are there any areas where you would like me to focus during
your massage session? Is there anything else you would like
me to know about your health or pregnancy?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Are there any areas where you would prefer not to receive
massage today?
__________________________________________________________________________________________
I generally prefer: ______ music without words
______ music with words
______ no music
______ no preference
When I receive massage, I usually prefer:
______ to chat with the therapist
______ to be spoken to only to check in about pressure and
comfort level
______ almost complete silence
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