Please print the Baby Massage Health Check Form from the desktop site.

BABY MASSAGE HEALTH CHECK FORM

IMPORTANT please tick box to confirm you have read DO NOT MASSAGE YOUR BABY IF...which can be found  

under Additional Information.

Name  ...............................................................................................  Surname .........................................................................................

 

Address ........................................................................................................................................................................................................

 

......................................................................................................................................................................................................................

 

Tel No .............................................................................................  Mobile ...............................................................................................

 

Email Address .............................................................................................................................................................................................

 

Children's Centre ...........................................................  Course Date ...................    Health Visitor ......................................................

 

Child's Details 

 

Name ............................................................................    Surname ...................................................................   Male/Female

 

Date of Birth ................................................................     Birth Weight .....................................................................................................

 

Type of birth and any other relevant information which is of concern to you .......................................................................................

 

......................................................................................................................................................................................................................

 

Paediatric check 6/10 weeks      Yes                     No  

 

Disclaimer:  if your baby has not had his/her paediatric check, please tick here to indicate your consent for your baby to undertake this infant massage course

 

Allergies     Yes                No                         Please state...........................................................................................................................

 

......................................................................................................................................................................................................................

 

Breast Fed                  Bottle Fed

 

Vaccinations    FIRST   SECOND   THIRD                Reactions      Yes                  No

 

Is your baby displaying any of the following:

 

Vomitting        Yes            No                                     Diarrhoea                      Yes            No

Skin Rash        Yes            No                                     Constipation                 Yes            No

Infections        Yes            No                                     Temperature/fever      Yes            No

Cut/wounds    Yes            No                                     Bruising/swelling         Yes            No

Colic                 Yes            No                                      Scars/inflammation    Yes            No

 

 

 

 

 

Signed ..................................................................                     Date ...............................................................................

 

Please print off completed Form and bring with you on the day of the Course 

* To print this Form use your browser's print function

 

 

IF THE ABOVE INFORMATION FOR YOU OR YOUR BABY SHOULD CHANGE DURING THIS COURSE PLEASE LET ME KNOW

 

 

ALL DETAILS ARE KEPT STRICTLY CONFIDENTIAL