A Health Questionnaire Template for Pregnancy Massage Therapists

24 Oct

 

Pregnancy Pre-Therapy Health & Lifestyle Questionnaire

Client Name:

DOB:

Client Address:

Client Phone No:

Client Email:

 Due Date/No. Of Weeks Pregnant:

 

Health Care Provider Details:

 

First Impressions/Visual Assessment

 

 

 

 

 

 

Reason for seeking therapy today? Where do you have pain/discomfort?  (Use Body Map Diagram).

 

Any excessive or sudden swelling and water retention?

History of miscarriages?

Any history or blood clots or Thrombosis? Any extreme calf pain, swelling or redness?

Last visit to Primary Health Provider and outcome?  Scan results?

 

Any severe and chronic itching (globally) ?

Extreme high blood pressure – current and previous history?

 

Any excessive thirst and urination? Gestational or Controlled Type 1 or 2 Diabetes?

Any rapid or large weight gain while Pregnant?

 

 

Any varicose veins or haemorrhoids?

Any Varicose Veins?

Current multiple pregnancy?

 

Any Bleeding During Pregnancy?

Any skin rashes, open or unhealed cuts or bruises?

 

Any Headaches, Blurred Vision, Vomiting today or recently?

 

Any previous/recent illnesses or injuries or hospitalization?

Any Symphysis Pubis Dysfunction or other Pelvic Pain?

 

Any strange/worrying physical symptoms during your pregnancy recently or previously?

Notes/Treatment Plan & Session Outcome/Follow-Up

 

 

 

 

 

 

 

 

 

 

www.burrelleducation.com – Passionate About Pregnancy & Post Natal Health & Fitness Education FOREVER! 

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