Full Name
Address Including Postcode
Home Telephone
Mobile Number
Email Address
Occupation
How Many Weeks Pregnant Are You?
What Is Your Estimated Due Date?
How Did You Hear About Urban Kneads?
Is This A Multiple Pregnancy?
Have You Suffered Or Are You Suffering From Any Of The Following?
If YES to any of the above OR if you suffer from any other medical condition or injury not mentioned, please give details:
Are You On Medication?
Have You Had Recent Surgery?
By initialing the box below you are confirming that all information given is correct and up to date. For your own safety please inform your massage therapist or yoga class instructor at the start of any class if there are any changes or if any physical or medical problems occur during the treatment or class.
Your Initials
Date
Please tell us how you would like to pay:
Thank You
High blood pressure
Back pain
Nausea/Morning Sickness
Varicose veins
Tiredness
Depression
Pubic pain
Abdominal pain
Anaemia
Heartburn
Constipation
Asthma
Cramps
Epilepsy
Insomnia
Heavy vaginal discharge
Pre-eclampsia
Diabetes
Contagious illness
Fever
Vomiting/Diarrhoea
Any malignant condition
Unusual pain
Previous problem pregnancy
Multiple miscarriages (3+)
RH-negative factors
Genetic problems
Uterine abnormalities
Intrauterine growth retardation/abnormal foetal development or heartbeat
Heart/lung/liver condition
Any undiagnosed lumps
Skin disorders
To book your pregnancy massage or a place on the pregnancy yoga course,
please complete the following form.
Your details will be kept confidential.
Booking Form For Pregnancy Yoga & Pregnancy Massage
