Prenatal Reflexology Intake Form
Please complete this form to help us assess your suitability for prenatal reflexology and prepare for your session.
Full Name
*
First Name
Last Name
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
How many weeks pregnant are you?
*
Have you experienced any complications during this pregnancy?
*
No complications
Gestational diabetes
High blood pressure
Preeclampsia
Placenta previa
Other (please specify)
Do you have any existing medical conditions?
*
None
Diabetes
Hypertension
Thyroid disorder
Blood clotting disorder
Other (please specify)
Are you currently taking any medications or supplements?
*
No
Yes (please list below)
Do you have any allergies (including to oils, lotions, or latex)?
*
No allergies
Yes (please specify)
What are your main reasons for seeking prenatal reflexology?
*
General relaxation
Reduce swelling
Relieve back pain
Improve sleep
Reduce stress or anxiety
Other (please specify)
How did you hear about our prenatal reflexology services?
Please Select
Doctor or midwife referral
Friend or family
Online search
Social media
Other
Submit Intake
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