Massage Therapy Prenatal Session Intake

Massage Therapy Prenatal Session Intake — Form Fields

This healthcare template includes 14 fields. Prenatal-specific intake form for massage therapy sessions during pregnancy. Free to customize and use on ZenBuild.

• Full Name (text, required)
• Date of Birth (text, required)
• Email (email, required)
• Phone Number (text, required)
• OB/GYN Provider Name (text, required)
• Weeks Pregnant (number, required)
• Trimester (dropdown selection, required) — options: First (1-12 weeks), Second (13-27 weeks), Third (28-40 weeks)
• High-Risk Pregnancy (multiple choice, required) — options: Yes, No
• Current Symptoms (checkboxes, optional) — options: Back Pain, Sciatica, Swollen Feet/Ankles, Headaches, Neck Tension, Hip Pain, Carpal Tunnel, Insomnia, Leg Cramps
• History of Pre-Term Labor (multiple choice, required) — options: Yes, No
• Placenta Previa (multiple choice, required) — options: Yes, No, Unknown
• Massage Pressure Preference (dropdown selection, required) — options: Light, Light to Medium, Medium, Firm (third trimester caution)
• OB/GYN Clearance Obtained (multiple choice, required) — options: Yes, No, Will Obtain
• Areas to Avoid or Focus On (long text, optional)