Preparation For Pregnancy Form

Preparation for Pregnancy

Please complete this form before the day of your treatment, so that I can get to know you and your needs. If there are any questions that you don't feel comfortable answering you can leave them blank.

If you have any questions for me before your treatment, please feel free to get in touch either by whatsapp or email.

Thank you for booking with me and I look forward to meeting you at the therapy room soon.

First name

Last name

Date of birth

Day

Month

Year

Address

Phone

Emergency Contact Name and Number

Date of visit

Day

Month

Year

Do you have any current or previous medical conditions that could potentially contra-indicate this treatment

Such as, infectious diseases, current migraine, acute injuries or inflammation, serious cardiovascular issues like blood clots (DVT), fever, severe skin conditions (like open wounds), active cancer, and recent surgery or fractures.

How long have you been trying to conceive?

Have you had any previous pregnancies?

How would you describe your menstrual cycle:

Regular/irregular, light/heavy, cysts/fibroids, Endometriosis etc

How would you describe your lifestyle

Regulated/unregulated, active/sedentary, stressful, relaxed, busy etc.

Would you be interested in receiving ayurvedic advice to support your TTC journey

Yes

Which drink would you like included in your treatment

Ayurvedic milky chai

Vegan ayurvedic chai

Fresh ginger and lemon tea

CCF tea

Disclaimers

Please ensure that you have completed all relevant questions and then complete the following disclaimers.

I understand that it is my responsibility and not that of the therapist to consult with my doctor regarding suitability of receiving this treatment if I so wish to.

Yes

I understand that the service is for general wellness, relaxation, and stress reduction, not a substitute for medical examination, diagnosis, or treatment by a doctor, or other qualified medical specialist.

Yes