Postnatal Massage Client Intake Form

Your Personal Details

Your best phone number

Emergency Contact Details

Reason for appointment

What is the primary reason or motivation for your appointment? Please also include areas of pain or tension.

If you’ve had massage during or after pregnancy before, tell me about your experience below (optional).

Pregnancy/Birth History & Details

This information is requested to support your care. Some questions are required to support safe postnatal bodywork. Others are optional and you are welcome to answer only what feels comfortable - you can share more or less on the day.

Date your baby was born?

What was the length of gestation (weeks)?

Have you birthed other babies? If yes, please provide age of children.

How did your baby arrive

Assisted vaginal (forceps / vacuum)

Caesarean (planned or emergency)

Did your baby require any special care after birth?

Are you currently breastfeeding or chest-feeding?

Please select any answers that are are YES:

Do you have current or recent pospartum bleeding concerns that require medical review?

Do you have any discharge from your suture or incision site?

Do you have any redness, warmth, drainage, or tenderness at your caesarean scar?

Do you have any redness or heat in the breasts?

Do you have unusual swelling or warmth in the calves?

Did you have extended bed rest before or after birth?

Did you experience any medical interventions during birth that I should be aware of?

If you answered yes to any of the above questions, please give further details:

Have you received clearance from your GP/midwife to receive postnatal massage?

Not yet but planning to

Your Medical History & Considerations

Have you experienced any of the following during pregnancy or now (postnatal)?

Heart/Blood circulation disorders

Osteoporosis / Arthritis

Chronic hypertension

Blood clot or thromboplebitis

Placenta insufficiency (if relevant during pregnancy)

Sciatica/gluteal pain

Separation of symphysis pubis

Separation of abdominal muscles

Preeclampsia (if relevant during pregnancy)

Are you currently taking medications? Please provide details below:

Do you have any allergies or sensitivities (including oils, scents)? If yes please describe below.

Mental & Emotional Wellbeing

How are you sleeping?

Getting reasonable rest between feeds

Struggling to sleep even when I have the chance

Barely sleeping / feeling wired or unable to switch off

How would you describe your overall energy levels since giving birth?

The postnatal period can be emotionally tender. Is there anything you’d like me to be aware of so I can support you with care, please share below. (optional)

Is there anything else I need to know to ensure your comfort and safety during your appointment time? (optional)

I consent to be emailed post-session information after the massage. I acknowledge that this will also add me to Kate's mailing list to receive updates of any news, offers and upcoming events. Note: You will be able to unsubscribe at any time.

Yes, I consent to receive post-session information and occasional updates

Consent & Declaration

Please tick EACH statement below to show your agreement before signing.

I declare that the information I have provided on this form is, to the best of my knowledge, true and accurate, and that I have not intentionally withheld any information relevant to my treatment. I will inform Kate Dillon of any changes to my health status.

If I experience any pain or discomfort during the session, I will immediately inform Kate Dillon so that the pressure and/or technique may be adjusted to my level of comfort.

I acknowledge that massage therapy is not a substitute for medical care, examination, or diagnosis.

It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent to receive treatment.

By booking, I agree to Kate Dillon's Cancellation & Late Arrival Policy: https://katedillon.net/policies/