Pregnancy Release Form (Page 3 of 6) in pdf

Intermezzo Massage

Denise Renee, CMT, RMT

Pregnancy Release Form

Pregnancy Questionnaire

1. How is your pregnancy going? ___________________________________________________________

2. Is it what you expected? ________________________________________________________________

3. What is the due date? _________________________________________________________________

4. Who is the Obstetrician? _______________________________________________________________

5. Hospital, Free-standing Birthing or Home Birth? _____________________________________________

6. Fetal testing done to date? ______________________________________________________________

7. Do you know the sex of the baby? ________________________________________________________

8. If yes, have you picked out a name?_______________________________________________________

9. What are the most stressful aspects of your life at present?_____________________________________

10. What do you do to counter act stress? _____________________________________________________

11. Who do you turn to for support? __________________________________________________________

12. Previous birth experiences? _____________________________________________________________

13. What was the best thing about the experience? ______________________________________________

14. What is most important to you about this birth? ______________________________________________

15. What is your greatest fear about this birth?__________________________________________________

16. Reflect on a time you felt especially calm. What were the circumstances? _________________________

_______________________________________________________________________________________

17. What do you need most from our session? __________________________________________________

P.O. Box 57633 • Sherman Oaks, CA 91413 • Phone (818) 800-7247 • Fax (818) 784-5505

• DR@ • Page 3 of 6

Pregnancy Release Form Page 3