Prenatal Massage Session Note

Client: [name and identifier per practice policy]

Date of Service: [date]

Session Time: [start/end times or total duration]

Therapist: [name, credentials]

Visit Type: [initial prenatal / follow-up prenatal massage]

Pregnancy Context & Consent

• Gestational Age: [weeks+days; note source: client report / referral / calculated from EDD] (Write "unknown" if not provided. Do not infer from appearance.)
• EDD: [expected due date] (Write "unknown" if not provided.)
• Relevant Pregnancy Considerations: [complications, restrictions, or clearance status reported by client or referring provider] (Write "None reported" if none.)
• Informed Consent: [attestation statement confirming consent obtained before hands-on work, positioning plan reviewed, client informed they may pause or stop at any time, draping approach explained and accepted] (Note specific consent for abdominal work if performed.)

Subjective

[Client-reported concerns and goals in narrative format: chief concern with brief direct quote if helpful, symptom location and severity on 0–10 scale, changes since last session if applicable, position tolerance history, session goals] (Use massage-appropriate language; document symptoms as client-reported rather than medical diagnoses.)

Objective

Positioning & Supports: [positions used, bolster placement, approximate time in each position if supine was used]

Observations: [relevant within-scope findings: visible swelling with location/laterality, palpation findings, posture/gait observations] (Omit items not observed rather than marking "normal" or "not assessed.")

Treatment: [techniques/modalities used, regions treated, pressure level, avoided areas with rationale, pregnancy-specific modifications]

Assessment & Response

[Brief clinical impression connecting findings to session approach] (Use cautious language such as "consistent with" or "may be contributing to"; avoid definitive diagnostic statements.)

[Client response: positioning tolerance, symptom changes during/after session, any adverse symptoms and actions taken, before/after pain scores if obtained]

Plan

• Follow-up: [recommended timing and focus for next session]
• Self-Care Provided: [guidance given such as positioning tips or stretches] (Omit if none provided.)
• Referral/Escalation: [if concerning symptoms reported: advice given and client response] (Omit entirely if no concerns arose.)

Therapist Signature: [signature, credentials, date/time signed]