Welcome to The Radiance Space

It is a joy to welcome you. To ensure your comfort, well-being, and safety during this special stage of your life, please take a moment to complete this pregnancy intake form. The information you provide is confidential and will help us adapt your treatments to your current needs, offering you a safe and personalised experience.

Full name

Date of your birth

Dia

Mês

Ano

Pregnancy Information

How many weeks pregnant are you?

Baby's due date

Dia

Mês

Ano

Is this your first pregnancy?

Yes

No

Is your pregnancy considered high-risk?

Yes

No

Please provide details:

Do you have medical clearance to receive lymphatic drainage?

Yes

No

Are you attending regular prenatal check-ups?

Yes

No

Current Symptoms & Care

Are you currently taking any pregnancy-related medications? If yes, please specify:

Work title

Do you sit for long hours at work, computer or driving?

Yes

No

Do you feel pain or heaviness in your legs?

Yes

No

Do you wear compression stockings?

Yes

No

Do you experience shortness of breath or dizziness with light activities?

Yes

No

Do you experience back or pelvic pain?

Yes

No

Please indicate if you currently have or have had any of the following conditions:

High blood pressure / Pre-eclampsia

Gestational diabetes

Circulatory problems / Significant varicose veins

Thrombosis (history or current)

Recent infections, fever, or viral illness

Kidney or heart problems

Other (please explain)

If you selected 'Yes' to any of the options above, please explain:

Is there any area you would like me to pay more attention to?

Is there any additional information you would like to provide?

Terms & Conditions

I commit to following all the instructions provided to me. I also express my agreement and willingness to undergo the proposed treatment, assuming responsibility for any possible undesirable effects.

I agree

I confirm that the information provided is accurate to the best of my knowledge. I understand that lymphatic drainage is not a substitute for medical care and that treatments will be adapted to my individual condition.

I agree

Tratamentos Faciais

Welcome to The Radiance Space

Pregnancy Information

Current Symptoms & Care

Terms & Conditions