Pregnancy Massage Consultation Form Pregnancy Massage Consultation Form Any information given will be treated in the strictest confidence and will not be shared with any third party. All questions are optional, however it may affect your treatment if you do not answer or answer incorrectly. Name First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country PhoneEmail Date MM DD YYYY Doctors Name, Address, Telephone numberMedicationAre you currently taking medication?lifestyleHave you had any injuries or operations in the last 12 months?lifestyleDo you drink alcohol? How many units per day?lifestyleDo you smoke? How many per day?lifestyleDo you drink tea/coffee? How many cups per day?DietHow many portions of fruit and veg do you eat per day?Water/DietHow many glasses of water do you drink per day?Stress at work- 0 1 2 3 4 5 6 7 8 9 10 + (please choose a number)stress at home_ 0 1 2 3 4 5 6 7 8 9 10 + (please choose a number)Section BreakAbout youDo you suffer with any problems in the following areas?Health Diabetes? Pre-eclampsia Muscular aches and pains? High risk pregnancy? Problems with your placenta? Do you suffer with any problems in the following areas?Health (continued) Previous miscarriage? High Blood pressure? Foetus not in correct position? Bleeding, Spotting or Discharge? Back ache, Stiff joints? Do you suffer with any problems in the following areas?Health (continued) Bloating, Constipation, IBS? Alleries, Eczema, Heat Rash? Coughs, Colds, ? Headaches, Migraine, Stress? check box if any of these problems applies to youAgreementAGREEThe details on this form are an accurate record of my medical history and current conditions. I agree to pay the costs for the treatment and will endeavour to give 24 hours notice, or pay the full amount if I cancel or postpone my appointment. I agree that all discussions carried out between the therapist and myself during my treatment will be kept strictly confidential. By checking the "agree" box on this form indicates full understanding and agreement with the information on this form. DISCLAIMER - I confirm that I have understood the treatment that I am to receive and confirm that I am willing to proceed without confirmation from my own GP. I hereby indemnify the therapist against any adverse reaction obtained as a result of the treatment.