Pregnancy/Posnatal MassageSoft Tissue Therapy - Pre Treatment Questionnaire Name * First Name Last Name Email * Phone (###) ### #### Date of Birth MM DD YYYY Emergency Contact First Name Last Name Phone (###) ### #### Do you or have you suffered from any of the following: High/low blood pressure Heart Problems Diabetes Epilepsy Joint Problems (e.g. arthritis, inflammatory tissues) Skin Problems/Sensitivities Allergies Asthma If you answered 'yes' to any of the above please give details: Are you currently taking any medication or receiving any medical treatment? So you or have you had any major surgery, accidents or serious illnesses? Please give details of any specific issues you would like the treatment to help: Additional questions for postnatal treatment: How many weeks/months age did you give birth? Did you have any particular problems during your pregnancy? If so, please give details: Please give details about the birth of your baby: Are the medical profession (midwives, health visitors, consultants etc) happy with your recovery? Do you have any other children? If so, please give their ages and any particular details of their births (e.g. vaginal, c-section or VBAC births) If you would like me to work on a c-section scar please answer the following questions: How well do you feel the scar has healed? Were there any complications in the healing process? Do you have any particular concerns about your scar? Does it cause you pain or restrict your movement? Do you have altered sensation around the scar? What would you like to achieve from the scar work: Is there anything else you feel I should know? Thank you!
