Chillout Spa

Name

Mobile Phone

Date of Birth

Occupation

Emergency contact name and phone number

Leading care provider (name and contact details)

Have you received massage of any kind before?

Have you experienced any pregnancy complications that you have experienced either in this or previous pregnancies?

If yes, please tick for Miscarriage

If yes, please tick for Ectopic Pregnancy

If yes, please tick for Premature Labour

If yes, please tick for Pre-eclampsia or Eclampsia

If yes, please tick for Gestational Diabetes

If yes, please tick for Other

Please outline the progress of your 1st trimester via your scan results. (Note we are unable to offer you massage unless you have had a scan in case there is an undisclosed safety issue i.e. placenta praevia).

How many pregnancies have you experienced?

Due date

Number of weeks

Please indicate any conditions you are experiencing in this CURRENT pregnancy by clicking on the relevant boxes below.

Morning sickness, hyperemesis

Muscle cramps

Seizures or epilepsy

Allergies

Breathlessness/Asthma

High/low blood pressure

Varicose veins

Dizziness/Fainting

Anaemia

Skin conditions

Oedema/swelling

Fatigue

Headaches

Sciatica

Groin pain/pubic pain

Diabetes (gestational or mellitus)

Thrombosis (blood clots) leg pain

High levels of stress

Insomnia

Hypermobility

If yes, are there any areas of discomfort you are experiencing now?

Autoimmune issues, any inflammatory conditions e.g. lupus, rheumatoid arthritis, Crohn's Disease

Fibromyalgia

Kidney/bladder issues

Please list any other medical conditions, injuries or health concerns you have?

Have you had any surgery, botox treatments or fillers and if so when? Please note there are some treatments we are unable to perform within certain time frames of these treatments?

Please list any allergies you have or any reactions?

Please list any medications you are taking - (also include homeopathic or natural remedies or topical creams)

How are you? On a scale of 1-10 (with 1 being low and 10 being high) how would you rate your ACTIVITY levels?

How are you? On a scale of 1-10 how would you rate your LIFESTYLE?

How are you? On a scale of 1-10 how would you rate your DIET?

How are you? On a scale of 1-10 how ARE YOU TODAY?

What would you most like to get out of your treatment?

Is there anything else you would like to add?

Covid 19 - I have read, agreed and will adhere to the requirements as outlined on the Covid-19 page of the chilloutspa.co.nz website

Newsletter and information updates - Thanks for keeping me up to date with relevant information via newsletters or relevant emails.

I agree to review this form once we have met and discussed further, and then initial all pages to indicate that it is an accurate representation of our discussion.

Informed Consent - I HAVE COMPLETED THIS HEALTH FORM IN CONSULTATION WITH MY THERAPIST, AND THE INFORMATION PROVIDED IS TRUE TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT THIS IS NOT A MEDICAL CONSULTATION AND THAT THIS INFORMATION IS TO ENSURE I AM SAFE FOR PREGNANCY RELAXATION MASSAGE THERAPY. I HAVE DISCLOSED ANY AND ALL HIGH-RISK FACTORS OF MY PREGNANCY. I WILL UNDERTAKE TO INFORM MY THERAPIST IF THERE ARE CHANGES IN THE FUTURE.

Date

Signed (to be signed at first meeting)

Address

Message Sent.

Pregnancy Relaxation Massage Intake & Health Screen

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