Client Intake Form

Monica Faux-Kota Client Intake Form - Pregnancy Massage

Personal Information:

Name:    Referred by:

Address:    Zip code:    Phone #:

E-mail Address:

Today’s Date:    Birth date:    Occupation:

General Information:

It is our intention to provide you a safe and nurturing experience during or after your pregnancy. We need to be aware of conditions you have experienced in order to modify your session(s) in the best interest of you and your baby. Please carefully review and complete the information on the intake and release forms with your healthcare provider and obtain the necessary signatures before arriving at your first massage appointment.

Massage therapy during pregnancy or postpartum is not intended to replace prenatal and postpartum care. Used as a form of adjunctive healthcare, potential benefits include:

• Reduces stress and promotes relaxation and normal blood pressure

• Relieves muscle spasms, cramps, and myofascial pain, especially in the back, hips and legs.

• Increases blood and lymph circulation and supports the physiological process of pregnancy.

• Reduces stress on weight-bearing joints and eases musculoskeletal strain and pain.

• Provides emotional support and physical nurturance

• Enhances a woman’s kinesthetic awareness and her ability to relax deeply which may be helpful during delivery.

• Offers labor supportive techniques that may increase comfort during labor.

• Promotes shorter, less painful labors and reduction of complications, including prematurity, and interventions.

• Assists postpartum restoration of abdomen and weight-bearing muscles and joints.

• Provides new mothers postpartum support with the physical and emotional aspects of infant care.

• Promotes healing, including post-cesarean scars.

Prenatal Intake and Health History

1. What discomforts, pain, or other needs are you hoping to have addressed through massage therapy?

2. In what week of your pregnancy are you? What is your estimated due date?

Week:    Estimated due date:

3. Who is your birth partner?

4. Please describe your birth vision:

5. Do you have any medical conditions or current surgeries / procedures unrelated to pregnancy that I should be aware of?

6. Are you currently experiencing any infection or disorder?

7. Please list any medications you may be taking:

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

9. Please list any parts of your body that you do not want massaged:

Please indicate any of the high-risk factors, complications, or conditions listed below, and discuss your condition with your maternity healthcare provider.

Postpartum massage can begin 24 hours after delivery. If there were complications or a cesarean delivery, you must have written release from your healthcare provider if you wish to receive massage in the first six weeks postpartum.

High risk factors (please check all that apply):

Pregnancy Complications (please check all that apply):

Non-pregnancy related complications (please check all that apply):

Contraindicated for affected areas only:

To: Client

Re: Release

I verify that I have discussed with my maternity healthcare provider the health concerns that I have about massage therapy and that (check one):

I have not had nor do I now have any prenatal complications nor any of the conditions listed. I have noted all prenatal complications, risks, or conditions I am / have experienced AND I have obtained my maternity healthcare provider’s release.

It has been made very clear to me that massage therapy is not a substitute for medical examination and/or diagnosis and that it is recommended that I see a physician and my maternity healthcare provider for any physical ailment and concerns with my pregnancy.

I, the undersigned, am aware that my therapist is associated with Monica Faux Kota Massage. I release Monica Faux Kota Massage and my therapist from any liability associated with my or my child’s massage therapy sessions. Because my therapist must be made aware of existing physical conditions, I have stated all my known medical conditions and take it upon myself to keep the therapist updated on my physical health and any changes in my pregnancy.

Massage therapy can sometimes trigger emotional releases that are associated with emotional, physical, mental, social and spiritual life experiences. It is very normal to feel sensitive and emotional during and/or after a massage. Also, in my interest to serve a variety of needs I have received advanced training in supporting survivors of abuse.

Please know that you are welcome to discuss any of your concerns with me.

To: Maternity Healthcare Providers

Re: Release for Therapeutic Massage During Pregnancy/Postpartum

Your Patient, , has requested therapeutic massage by a certified Pre- and Perinatal Massage therapist (certification requires completion of a comprehensive hands on training program as well as passing both a written and practical exam).

It is our policy to work on her in consultation with her maternity healthcare provider. Please review this request with her. In addition, if her pregnancy is high-risk, or she has experienced any complications or contraindicated conditions, we require a written release from her healthcare provider stating any specific limitations or precautions that you feel to be appropriate.

Please verify your clearance of this request by your signature below. This verification can be modified or withdrawn at any time should your patient’s health status change. Thank you for your time and assistance.

Patient’s pregnancy is (please circle one):

normal progression high-risk

Specific limitations or precautions:

You may contact me directly for clarification or concerns regarding this patient.

Yes  /  No