Pregnancy Pre-Therapy Health & Lifestyle Questionnaire
Please complete the following initial consultation and email to ninalou22@hotmail.com. This must be completed
before commencing any therapy. In the case of ‘high risk’ pregnancies, it is also valuable to ensure that you have
been given permission to seek and take part in the therapy I am offering you.
Name:
Due Date and Number of Weeks Pregnant:
Address:
Health Care Provider Details (midwife name GP surgery and
contact number for midwife/GP
Phone No:
Permission to contact? YES [ ] No [ ]:
Email:
First Impressions/Visual Assessment (to be completed at face to face appointment)
Please complete fully and give as much information as possible.
Reason for seeking therapy today? Where do you have
pain/discomfort? (Please mark on Body Map Diagram)
Recent visit to Primary Health Provider and
outcome? Scan results/placental location?
Need to put body map diagram here nicola
Any skin rashes, open or unhealed cuts or bruises?
Any history of blood clots? Any extreme calf pain,
swelling or redness?
Any swelling to face, calves, feet and/or hands? Sudden
onset?
Any severe and chronic itching?
Extreme high blood pressure – current and previous
history?
Any excessive thirst and urination?
Any rapid or large weight gain in Pregnancy? What weight
have you gained?
Any varicose veins or haemorrhoids?
Any extreme itchiness?
Current multiple pregnancy?
History of miscarriages?
Any other relevant information or medical
condition that is not already mentioned?
Currently, or during previous pregnancies have you suffered any of the following conditions?
Symphysis Pubis Dysfunction (SPD)
Sacrum or SIJ Pain
Bleeding during pregnancy
Carpal Tunnel Syndrome
Knee Pain
Low Back Pain
Upper Back Pain
Neck Pain
Coccyx Damage or Pain
Separation of your abdominal
muscles
Varicose Veins
Gestational Diabetes
Any other conditions not stated that you feel are important to mention?
CLIENT INFORMED CONSENT TO MASSAGE THERAPY TREATMENT
I understand that the massage therapist is providing massage therapy services within their scope of practice as defined by
the qualifications attained.
I hereby consent for my therapist to treat me with massage therapy for the above noted purposes including such
assessments, examinations and techniques, which may be recommended, by my therapist. I acknowledge that the therapist
is not a physician and does not diagnose illness, disease, or any other physical or mental disorder.
I clearly understand that massage therapy is not a substitute for a medical examination. It is recommended that I attend
my General Practitioner for any ailments that I may be experiencing. I acknowledge that no assurance or guarantee has
been provided to me as to the results of the treatment. I acknowledge that with any treatment, there can be risks and those
risks have been explained to me and I assume those risks.
I acknowledge and understand that the therapist must be fully aware of my existing medical conditions. I have completed
my medical history form as provided by my therapist and disclosed to the therapist all of those medical conditions affecting
me. The information I have provided is true and complete to the best of my knowledge. If I have a specific medical condition
or specific symptoms for which massage may be contraindicated, a referral from my primary care provider may be required
before services are provided., It is my responsibility to keep the massage therapist updated on my medical history and
understand and agree that there shall be no liability on the therapist part should I fail to do so.
I have read the above noted consent and I have had the opportunity to question the contents and my therapy. By signing
this form, I confirm my consent to treatment and intend this consent to cover the treatment discussed with me and such
additional treatment as proposed by my therapist, to deal with my physical condition and for which I have sought treatment.
I understand that at any time, I may withdraw my consent and treatment will be stopped.
If I experience any pain or discomfort during this session, I will immediately inform the therapist so that the pressure and/or
strokes may be adjusted to my level of comfort.
Patient Name and signature and date
______________________________________________________________________
Date
The above information about me is current and there
are no changes that I need to make my therapist aware
of (sign)
I have changes from the above information and have
informed my therapist – additional notes attached.
Post Natal Pre-Therapy Health & Lifestyle Questionnaire
Please complete the following initial consultation and email to ninalou22@hotmail.com. This must be completed before
commencing any therapy. In the case of medical conditions, it is also valuable to ensure that you have been given
permission to seek and take part in the therapy I am offering you from your health care provider.
Name:
Number of Weeks Post Natal:
Address:
Health Care Provider Details (name, address, contact number:
Phone No:
Permission to contact? YES [ ] No [ ]:
Email:
First Impressions/Visual Assessment (to be completed at the first face to face consultation)
Reason for seeking Therapy today? Where do you have pain/discomfort? Please mark on Body Map Diagram
NEED TO PUT BODY MAP PICTURE HERE NICOLA
Last visit to Primary Health Provider and outcome?
6 week check-up carried out?
Have you, or are you currently suffering from any of the following conditions? Please give details
Symphysis Pubis Dysfunction
Sacrum or SIJ Pain
Low Back Pain
Carpal Tunnel Syndrome
Knee Pain
Coccyx Damage or Pain
Upper Back Pain
Neck Pain
After-effects of Gestational
Diabetes
Separation of your abdominal
muscles
Varicose Veins
Piles/Haemorrhoids
Any other condition not mentioned? You can use this space to add further information if needed.
Are you currently, or have you ever experienced the following problems after the Birth?
Fever?
Prolonged postnatal bleeding (more than 8 weeks)?
Burning sensation whilst passing urine?
Passing blood clots or heavy bleeding ?
Difficulty passing urine or leakage of urine?
Resumed bleeding after cessation?
Swollen, red, painful area(s) on calves or lower legs?
Increase pain/discomfort/poor healing at
Episiotomy site?
Painful breasts?
Increased pain/discomfort/poor healing at the
caesarean or perineum area?
Sore, itchy vagina and discharge?
Anything else not mentioned?
CLIENT INFORMED CONSENT TO MASSAGE THERAPY TREATMENT
I understand that the massage therapist is providing massage therapy services within their scope of practice as defined by
the qualifications attained.
I hereby consent for my therapist to treat me with massage therapy for the above noted purposes including such
assessments, examinations and techniques, which may be recommended, by my therapist. I acknowledge that the therapist
is not a physician and does not diagnose illness, disease, or any other physical or mental disorder.
I clearly understand that massage therapy is not a substitute for a medical examination. It is recommended that I attend
my General Practitioner for any ailments that I may be experiencing. I acknowledge that no assurance or guarantee has
been provided to me as to the results of the treatment. I acknowledge that with any treatment, there can be risks and those
risks have been explained to me and I assume those risks.
I acknowledge and understand that the therapist must be fully aware of my existing medical conditions. I have completed
my medical history form as provided by my therapist and disclosed to the therapist all of those medical conditions affecting
me. The information I have provided is true and complete to the best of my knowledge. If I have a specific medical condition
or specific symptoms for which massage may be contraindicated, a referral from my primary care provider may be required
before services are provided., It is my responsibility to keep the massage therapist updated on my medical history and
understand and agree that there shall be no liability on the therapist part should I fail to do so.
I have read the above noted consent and I have had the opportunity to question the contents and my therapy. By signing
this form, I confirm my consent to treatment and intend this consent to cover the treatment discussed with me and such
additional treatment as proposed by my therapist, to deal with my physical condition and for which I have sought treatment.
I understand that at any time, I may withdraw my consent and treatment will be stopped.
If I experience any pain or discomfort during this session, I will immediately inform the therapist so that the pressure and/or
strokes may be adjusted to my level of comfort.
Patient Name and signature and date
______________________________________________________________________
Date
The above information about me is current and there
are no changes that I need to make my therapist aware
of (sign)
I have changes from the above information and have
informed my therapist – additional notes attached.
Seeking Permission from Clients’ GP for Therapy
10th March, 2006.
Dr. Parker,
Kensington Surgery,
Poole Road,
London,
W14 4JK.
Dear Dr. Parker
Re: Gemma Brown, 56 Target Road, Willesden, NW1.
DOB: 4.12.74 – 22 Weeks Pregnant
Gemma has attended my clinic requesting a session of massage and remedial therapy because of various
muscularskeletal issues relating to the postural changes of pregnancy.
I have asked Gemma to seek your permission for massage as she is expecting twins and multiple births are a ‘reason to
seek permission’ to receiving massage therapy and it is deemed good practice to seek permission from the clients’ HCP.
Type of Therapy Proposed:
Your permission to proceed or advice regarding the treatment options for Gemma would be greatly appreciated.
Yours Sincerely,
Jenny Burrell, BSc (Hons), ITEC, BTEC
Pregnancy & Post Natal Massage & Remedial Therapy Specialist
Planning Your Awesome Session
Welcome & Begin
Areas Of Focus
1.
2.
3.
4.
5.
Notes
Elevated Supine
Areas Of Focus
1.
2.
3.
4.
5.
Notes
Side Lying – Top Leg Exposed
Areas Of Focus
1.
2.
3.
4.
5.
Notes
Side Lying - Bottom Leg Exposed
Areas Of Focus
1.
2.
3.
4.
5.
Notes
Side Lying – Back 1
Areas Of Focus
1.
2.
3.
4.
5.
Notes
Side Lying – Back 2
Areas Of Focus
1.
2.
3.
4.
5.
Notes
Ending
Areas Of Focus
1.
2.
3.
4.
5.
Notes