Prenatal Massage Release Form-Bellezzaangels.com

Prenatal Massage Release Form

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Prenatal Massage Release Form

Prenatal Massage Contraindications

Massage therapy during pregnancy has been shown to be beneficial for a number of common complaints suchas fatigue, musculoskeletal pain, sciatica, edema, and many others. However, there are risks associated withspecific conditions that may occur during pregnancy. You must inform your massage therapist/practitioner if you have or have had in the past any of the following conditions or symptoms which may make massage therapy during pregnancy contraindicated or may require your therapist/practitioner to alter the massage.

• History of miscarriage • Preeclampsia

• Gestational Diabetes • History of any high-risk pregnancy

• Cardiac, pulmonary, liver, or renal disorders • Drug exposure

• Mother’s age under 20 or over 35 • Multiples

• Pitting edema • Hypertension

• Epilepsy or other convulsive disorders • Genetic abnormalities

• Placental or cervical dysfunction • Fetal growth retardation

• Abdominal pain • Bloody discharge

• Leaking of amniotic fluid • Sudden weight gain

• Fever • Diarrhea

• Sudden edema/swelling • Decrease in fetal movement over 24-hour period

• Severe headaches • Severe nausea or vomiting

(1) I am receiving medical care including regular check-ups with a licensed healthcare provider.

(2) I have not experienced any of the listed symptoms.

Client’s Release I, ____________________________________, have read the aforementioned conditions and symptoms which make massage therapy during pregnancy contraindicated. The massage therapist/practitioner has discussed this information with me and

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