Client Pregnancy Treatment Consultation Form
The following information will be used to help plan a safe and effective treatment. Please answer the questions to the best of your knowledge. All information will remain private & confidential.
Treatment Required
Massage Reflexology Facial Treatment
Name*
First Name Last Name
Date of Birth*
Month Day Year
Date
Pregnancy Week*
Due Date*
Month Day Year
Date
Address*
Street Address
Street Address Line 2
City
Country
Phone Number*
Prefix Phone Number
E-mail*
Occupation
Emergency Contact Name & Mobile*
Primary Care Provider Name & Address*
Last visit to Primary Care Provider*
Month Day Year
Date
How did you hear about me?*
Website / Online Search Instagram Facebook Referral Other
If Referral, please list name
If Other, please let me know
What is the objective of your visit (eg: relaxation, specific condition / pain)?*
Pregnancy Information:
Do you suffer from any of the following pregnancy related conditions?*
Backache Morning Sickness Heartburn Headaches / Migraine Sinuses Depression / Anxiety / Panic Attacks Diarrhea / Constipation / IBS Sciatica Anemia Oedema (Swelling) High Blood Pressure Low Blood Pressure Palpations Varicose Veins Haemorrhoids Pelvic Girdle Instability Symphysis Pubis Laxity Capal Tunnel Syndrome Vaginal Bleeding Abdominal Pain Sensory Loss (numbness) Urination Issues Leg Cramping / Pain Clotting issue (suspected deep vein thrombosis) Protein, sugar or blood in urine Any other conditions not listed here (please go into detail below)
Please detail any other conditions:
Current Medication (incl vitamins):*
Your General Health
Stress Levels at Home*
High Medium Low
Are you currently working outside the home (occupation please if yes)?
Stress Levels at Work*
High Medium Low n/a
Exercise / Hobbies?
Have you experienced any of these health conditions in the past or present?*
Hormone Imbalance (eg PCOS / irregular cycle) Cancer High Blood Pressure Diabetes Heart problem Arthritis Auto-Immune Disorders Asthma Epilepsy / Seizure Disorder Fever Blisters Herpes Frequent Cold Sores HIV/AIDS Lupus Depression/Anxiety Hepatitis Headaches / Migraines Covid-19 Other None
If you checked yes to any of these please provide further information. If not mark N/A*
Any known allergies (eg: aspirin, latex, nuts, essential oils)?*
Yes No
Are you a smoker?*
Yes No Social
Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)*
Yes No
Do you drink alcohol*
Yes No
What is your daily water intake (glasses / litres)*
Have you ever experienced claustrophobia?*
Yes No
Is there any other information you would like to make your therapist aware of? If yes, please give details:
Reservation & Cancellation Policy for all current and future appointments: In the event of cancellations received less than 24 hours prior to appointment a cancellation fee equal to the reserved service booking will incur. No Shows will be charged 100%. Suspected Covid-19 and severe pregnancy related issues are exceptions to this rule, but please do let me know asap*
I understand the reservation and cancellation policies at Renew Therapies and consent to my credit card on file being charged if I fail to give the required notice.
I knowingly and willingly consent to attending for a complimentary treatment during the COVID-19 pandemic.*
By checking this box I understand and accept this statement
CLIENT DECLARATION: I declare that the information I have given is correct and as far as I am aware I can undertake a treatment with out any adverse effects. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and I am willing to proceed. I understand that complimentary therapies do not substitute medical treatment. If I experience any discomfort during the treatment I will inform the therapist immediately, so that the products/techniques can be adjusted. The treatments I receive here are voluntary and I release the therapy from liability and assume full responsibility thereof. I understand that my therapist may require me to obtain permission from my doctor before my appointment.*
By checking this box I understand and accept this statement
I occasionally contact clients to follow up on a session and I also send booking confirmation and a reminder via email / SMS. I occasionally send emails regarding company news, updates, special offers etc. You may unsubscribe from these marketing emails at any time. Please confirm you give your permission for Renew Therapies to:*
Contact you about appointment and relevant follow up. Send occasional emails with news, special offers etc.
Signature*
Clear
Thank you for taking the time to complete this form - I look forward to seeing you soon.
Jennifer
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