Fertility Massage Intake Form
Please help us provide you with a complete evaluation by taking the time to fill out this questionnaire carefully. All answers are confidential.
If someone referred you to us, whom specifically may we thank?
How long have you been actively trying to conceive?
Are you seeing a fertility specialist? Yes No
If so, what treatments are you currently undergoing?
Date of Last Menstruation:
No. of Pregnancies: No. of Births: Any Miscarriages: Yes No
Are your menstrual cycles regular? Yes No
How many days from the start of one period to the next:
Are you tracking your ovulation? Yes No
If so, what method are you using?
What do you think may be inhibiting conception?
Hormones Congestion Timing Age Diet Lifestyle
*Are you allergic to any oils or nuts? Yes No
If yes, please specify:
List any other allergies and your reaction:
DIET: What might you eat on a typical day?
What non-work activities do you enjoy doing? (Reading, TV, meditation, music, etc.)
Have you consulted a nutritionist, herbalist or acupuncturist? Yes No
If yes, check which ones:
Nutritionist Herbalist Acupuncturist
Have you ever experienced a therapeutic massage? Yes No
Do you currently have any areas of discomfort?
Do you have any past injuries or surgeries that I should know about?
Are you seeking out and are open to other alternative therapies? This would include Chinese herbal medicine, acupuncture, health coaching, yoga, and meditation. Yes No
Please circle which you would be interested in:
Chinese herbal medicine Acupuncture Health coaching Yoga Meditation
Is your partner open to receiving therapeutic massage? Yes No
Would you and your partner be interested in an instructional session to give you tools for using therapeutic massage on each other?
Using the images above and letters below, please indicate which areas are of concern (for example pain and tenderness in the right area of the head would be notated by 1-O):
Pain and Tenderness = O
Numbness and Tingling = Z
Swelling and Stiffness = X
The information I have provided is true and correct to the best of my ability.
Massage Therapy - Informed Consent
- I hereby voluntarily consent to massage therapy.
- I understand that massage therapy is for the purpose of stress reduction, relief from muscular tension or spasm, for increasing circulation, energy flow and relief from stiff joints. The procedures have been fully explained to me.
- I understand that the massage therapist does not diagnose illness, disease, or any other conditions.
- I affirm that I have stated all my known medical conditions and answered questions honestly, since there may be possible contraindications with massage therapy. I agree to keep the massage therapist updated as to any changes in the above and void any liability on the therapist’s part should I forget.
- I understand both therapist and client have the right to terminate a session for any reason. The client is responsible for the fee of that scheduled appointment.
- Inappropriate sexual conduct will result in termination of the session with the client responsible for the fee of that scheduled appointment.
- I understand that no guarantees concerning its use and effects are given to me, and that I am free to stop massage therapy treatment at any time.
- I understand and agree that I am responsible for payment of all fees associated with treatment. If I am using health insurance or other third-party payment options, I understand that I am responsible for all fees that are not covered.
- I understand and agree to pay the full fee for appointments cancelled with less than 24 hours notice.
- I have carefully read and understand all the foregoing and so am fully aware of what I am signing. I have felt free to ask any questions.