Rebalance
MASSAGE THERAPY
BY AMANDA STAMP
Pregnancy Massage consultation form
4 WEEK BABY MASSAGE COURSE
Before your massage with me, I require you to COMPLETE and SUBMIT this consultation form. All information will remain strictly confidential. If you want to fill in a consultation form for a pregnancy massage or for the baby massage course please follow the links below.
Massage Consultation Form
MENOPAUSE
Are you pregnant?
CHANGES IN MENSTRUAL CYCLE
CHANGES IN FREQUENCY OF URINATION
BURNING SENSATION ON URINATION
PROBLEMS PASSING WATER (URINATION)
nausea
Diarrhoea
Constipation
Palpitations
Persistent Coughing
Shortness of breath
Chest Pain
Do you suffer from any of the following?
Menopause
Are You Pregnant?
Changes In Menstrual Cycle
Changes In Frequency Of Urination
Burning Sensation On Urination
Problems passing water (urination)
Nausea
Diarrhoea
Constipation
Palpitations
Persistent Coughing
Shortness Of Breath
Chest Pain
Do you suffer from any of the following? Please answer Yes or No to each of the following
Stress levels 1-10 (10 highest)
