About this template
The Pregnancy Therapies Consultation Google Form Template is designed for prenatal massage therapists, physical therapists, doulas, and specialized wellness practitioners. This comprehensive intake form collects essential client information, including contact details, emergency contacts, primary care provider information, current week of pregnancy, and expected due date.
Beyond basic demographics, the form delves into crucial health and lifestyle metrics needed to provide safe, tailored prenatal care. It covers current medications, daily water intake, stress levels, exercise habits, previous health conditions, allergies, and specific pregnancy-related symptoms. Detailed screening questions ensure practitioners are fully aware of any contraindications before beginning treatment.
Finally, the form incorporates necessary legal and operational safeguards by including reservation and cancellation policy agreements, COVID-19 treatment acknowledgments, client declarations, and consent signatures. By streamlining this intake process, practitioners can ensure client safety, maintain clear documentation, and focus entirely on delivering exceptional prenatal support.
Key features
- Capture complete prenatal health history and current pregnancy week
- Screen for lifestyle factors, stress levels, and daily habits safely
- Collect emergency contacts and primary care provider details
- Secure policy agreements, health declarations, and consent signatures
- Instantly deployable as a ready-to-use Google Form
Use cases
Prenatal massage therapy clinics evaluating new expectant clients
Maternity wellness centers conducting initial health and lifestyle sc…
Maternity wellness centers conducting initial health and lifestyle screenings
Physical therapists providing specialized orthopedic care during preg…
Physical therapists providing specialized orthopedic care during pregnancy
Holistic health practitioners gathering informed consent before treat…
Holistic health practitioners gathering informed consent before treatment
What this form collects
- Treatment Required (Dropdown)Select the specific therapy or service you are booking today.
- Full Name (Short answer)Enter your first and last name.
- Date of Birth (Date)Enter your date of birth.
- Current Week of Pregnancy (Short answer)Enter your current gestational week (e.g., 24 weeks).
- Estimated Due Date (Date)Enter your expected delivery date.
- Home Address (Paragraph)Enter your street address, city, and postal code.
- Phone Number (Short answer)Enter your primary mobile number for appointment reminders.
- Email Address (Short answer)Enter your email address.
- Occupation (Short answer)Enter your current occupation or job title.
- Emergency Contact Name & Mobile (Short answer)Provide the name and phone number of someone we can reach in case of an emergency.
- Primary Care Provider Details (Paragraph)Enter the name and clinic phone number of your OB/GYN, midwife, or primary physician.
- Date of Last Primary Care Visit (Date)When was your most recent prenatal checkup?
- Referral Source (Multiple choice)How did you hear about our practice?
- Visit Objective (Paragraph)What are your main goals or symptoms you hope to address today?
- Pregnancy-Related Conditions (Checkboxes)Select any conditions you are currently experiencing.
- Current Medications & Supplements (Paragraph)List all prescription medications, over-the-counter drugs, and prenatal vitamins you are currently taking.
- Home Stress Level (Linear scale)Rate your overall daily stress level at home.
- Work Stress Level (Linear scale)Rate your overall daily stress level at work.
- Exercise and Hobbies (Paragraph)Describe your regular physical activities, hobbies, or exercise routines.
- Health Conditions History (Paragraph)Do you have a history of blood clots, heart conditions, severe allergies, or recent surgeries?
- Smoking, Caffeine, and Alcohol Status (Paragraph)Please describe your current habits regarding caffeine, tobacco, and alcohol consumption.
- Daily Water Intake (Short answer)How many glasses of water do you typically drink per day?
- Claustrophobia or Positioning Concerns (Multiple choice)Do you experience claustrophobia or discomfort lying face down or on your side?
- Reservation & Cancellation Policy Acceptance (Multiple choice)Do you agree to our 24-hour cancellation policy?
- COVID-19 Treatment Consent (Multiple choice)Confirm that you are symptom-free and agree to our studio health and safety guidelines.
- Client Declaration & Signature (Short answer)By typing your full legal name below, you declare that all information provided is accurate to the best of your knowledge and that you consent to treatment.
FAQ
How do I use this pregnancy therapy consultation template?
Simply click the template link to copy it directly into your Google Drive as a fully editable Google Form. You can customize questions, add your clinic's branding, and share it with clients before their appointment.
Can I collect client signatures and policy agreements?
Yes. The form includes dedicated text and acknowledgement fields for cancellation policies, health declarations, and treatment consents to protect both your practice and your clients.
Is this form suitable for telehealth or remote intake?
Absolutely. You can email or text the Google Form link to clients so they can complete their consultation details securely from home before arriving at your clinic.
What kind of health information does this template capture?
It covers pregnancy week, due date, primary care provider details, current medications, allergies, lifestyle habits like caffeine and water intake, and specific pregnancy-related health conditions.
Can I modify the questions to fit my specific practice?
Yes, once the form is in your Google Forms account, you have complete control to add, remove, or edit any questions to match your exact clinical protocols.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.