About this template
A Prenatal Massage Client Intake Form is an essential digital document designed for massage therapists, wellness centers, and spas working with expectant mothers. Gathering comprehensive health details prior to an appointment is critical to ensuring a safe, relaxing, and tailored massage experience during pregnancy. This template collects vital information including contact details, current week of pregnancy, medical history, physician or midwife contact details, pregnancy-specific complications, and specific areas of discomfort or pain.
By streamlining your intake process with Doc2Form, you eliminate cumbersome paper forms and ensure that all necessary health clearances and informed consents are securely documented before the client arrives. This not only protects your practice by identifying potential contraindications early, but it also allows you to customize the massage session to target the client's exact needs, enhancing overall comfort and safety.
Key features
- Collect detailed pregnancy history and current week effortlessly
- Identify high-risk conditions or physician clearance requirements
- Pinpoint exact areas of discomfort, pain, and tension
- Obtain digital consent and emergency contact details securely
- Fully responsive format for clients filling out forms on mobile devices
Use cases
Initial intake for new prenatal massage clients at a wellness spa
Pre-session health screening for licensed massage therapists
Documenting physician approval for high-risk or late-term massage ses…
Documenting physician approval for high-risk or late-term massage sessions
What this form collects
- Full Name (Short answer)Enter your first and last name.
- Intake Date (Date)Select today's date.
- Phone Number (Short answer)Enter the best phone number to reach you.
- Email Address (Short answer)Enter your primary email for appointment confirmations.
- Birth Date (Date)Enter your date of birth.
- Emergency Contact Name and Phone (Short answer)Provide the name and phone number of someone we can contact in case of an emergency during your visit.
- Current Week of Pregnancy (Short answer)Enter your estimated week of pregnancy.
- Physician or Midwife Details (Paragraph)Please provide the name and phone number of your OB/GYN, midwife, or primary prenatal care provider.
- Are you experiencing any high-risk pregnancy symptoms or complications? (Paragraph)List any conditions such as preeclampsia, gestational diabetes, severe swelling, or unexplained spotting.
- Medical Conditions & Allergies (Paragraph)Describe any relevant medical conditions, recent surgeries, or product allergies we should be aware of.
- Current Medications (Paragraph)List any prescription medications, vitamins, or supplements you are currently taking.
- Areas of Discomfort or Pain (Checkboxes)Select all areas where you are currently experiencing tension, aches, or pain.
- Describe Your Pain or Tension (Paragraph)Provide details on the onset, frequency, or triggers of your discomfort.
- Previous Massage Experience (Multiple choice)Have you received professional prenatal massages before?
- Informed Consent and Acknowledgment (Multiple choice)Please confirm that you have disclosed all relevant medical information and consent to receiving prenatal massage therapy.
- Client Signature (Type Full Name) (Short answer)Typing your full name here serves as your digital signature and agreement.
FAQ
How do I share this intake form with my clients?
Once your Google Form is generated via Doc2Form, you can easily email the link to clients when they book, embed it on your booking website, or text it to them prior to their appointment.
Can I modify the questions to match my clinic's specific policies?
Yes! Because the template lives directly in your Google Drive, you have full control to add, edit, or remove any questions using the standard Google Forms editor.
Is it important to collect physician or midwife contact details?
Yes, for high-risk pregnancies or clients experiencing complications, having attending physician contact information is vital for ensuring safe therapeutic care.
How can I handle client signatures for consent?
You can include a required acknowledgment checkbox confirming that the client understands the risks and consents to treatment, or use a text field for a digital sign-off.
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.