Pregnancy Medical Declaration Form | Sarah's Health & Beauty

Pregnancy Medical Declaration

If you are pregnant, you must complete a Medical Declaration form before attending a massage with Sarah's Health and Beauty.

You can download and complete the form by clicking here. Please print the form and bring it along with you to your appointment.

Alternatively, you can complete the online form below. Once submitted, the form will be securely stored by Sarah's Health and Beauty, and only accessed before or during your treatments by Sarah.

Pregnancy Massage Client Intake Form

Personal Information

First Name

Last Name

Date of Birth

Phone no.

Address

Address Line 1

Address Line 2

City

County

Post Code

Occupation

Emergency Contact

Your relationship with Emergency Contact

Emergency Contact No :

How did you hear about us?

Previous Massage Experience

Please provide as much detail as possible.

Have you received massage therapy or bodywork before?

Yes

If yes, what....

How often?

Medical Information

Please provide as much detail as possible.

Are you taking any medication?

Yes

If yes, please list your medication

Do you exercise?

Yes

If yes, how often?

If yes, for how long?

Please list and explain any other conditions / symptons you have experienced

Have you had any serious or chronic illness, operations or traumatic accidents?

If yes, please explan

Pregnancy Information

Parental Care Provider / Doctor

Contact information

May I contact your care provider?

My due date is :

This is my 1st, 2nd, 3rd pregnancy etc

This is my 1st, 2nd, 3rd birth etc

I am ....... weeks pregnant

Sign and Date

Please type your name in BLOCK CAPITALS to act as your signature

Enter the date you completed this form