Prenatal/PostPartum Intake Form

Prenatal & Perinatal Client Health History Intake Form

My goal is to understand you ~ your health history, lived experiences, and how you are feeling so that I can tailor our sessions to your goals, health, and well-being. It is my intention to provide you a safe and nurturing Massage and Bodywork experience during or after your pregnancy. Please indicate any of the high risk factors, complications or conditions listed below. *If there are complications with your pregnancy, you are on bed rest, or your health care provider has deemed your pregnancy "at risk" , I request a written release from your health care provider clearing you for my Massage Therapy and Bodywork services.

Your answers help me better serve you. Thank You

Patient Name First, Last

Preferred Name/Pronouns

Birthday

Month

Day

Year

Email

Phone Number, please use format below

Address

Today's Date

What is your estimated due date or What was the date of delivery? And please list the dates of previous pregnancies.

In what week of pregnancy are you?

Are you regularly seeing a physician, nurse-midwife, midwife for care during your pregnancy?

When was your most recent visit with your provider? When is your next visit with your provider?

Has your provider identified any medical complications at any point during your pregnancy or postpartum healing?

Do you have any underlying medical conditions, recent surgeries/ previous surgeries or procedures that I should be aware of?

List any additions to your body ie. IUD, Mesh, Dental Appliance - MARPE/ALF, Plates, Screws, Rods, Joint Replacements, Stents, Pacemakers:

Are you currently experiencing any infection or disorder ?

Please list any medications you may be taking.

Is there other relevant information about this pregnancy, a previous pregnancy or about you that I should know ?

What needs are you hoping to address in your session? Any discomforts, pain or specific places your want tended to?

Please indicate any of the high-risk factors, complications or conditions listed below, and discuss with your maternity healthcare provider. *Postpartum Massage & Bodywork can begin as soon as 24 hours afer delivery. If there were complications, or a cesarean delivery, you must have written release from your healthcare provider if you wish to receive Massage & Bodywork in the first six weeks postpartum. Thank You

Non - Pregnancy Related Complications: Please check all that apply

Cancer or Undiagnosed Lumps

Autoimmune Disorder

Infection

Contraindicated for Affected Areas: Please check all that apply

Severe Varicose Veins

Skin Irritation / Discharge

Thrombophlebitis

Fracture / Bleeding / Burns / Other Injury

If any of the above affected areas were checked, please indicate locations of affected areas

List any allergies

Do you have any other medical or health conditions I should be aware of ?

Massage Therapy and Bodywork is NOT a subsitute for medical examination and or diagnosis.

Please Answer

I Agree

To the best of my knowledge the information I’ve provided on this form is true and complete and I will inform Vanessa of any changes in my health. I agree to inform my practitioner any time I feel that my well-being is being compromised, and I will inform Vanessa of any pain or discomfort during the session so that she may adjust the technique and props accordingly. I understand that Vanessa Escovar does not diagnose illness nor does she prescribe medical treatment. I acknowledge that Massage Therapy & Bodywork is not a substitute for medical examination or diagnosis. I, the undersigned release Vanessa Escovar CMT #65246 from any liability associated with my Massage Therapy & Bodywork Sessions.

Please Answer

I Agree

I understand that my appointment time is set aside just for me, and that 48-hour notice is required for all appointment changes. If not given, I agree that I am responsible for the full rate of the session fee. I understand and agree to the fees and billing policies of Vanessa Escovar as described in our communication.

Please Answer

Yes, I agree

Patient Signature

By signing this form electronically and clicking "Submit," you are agreeing to the terms as stated above.

CALIBRATE MASSAGE & BODYWORK

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Prenatal & Perinatal Client Health History Intake Form