Body Verb-Michell Rodriguez RN

Name

First NameLast Name

Date of birth*

Address

ADDRESS

Street Address Line 2

CITYSTATE

POSTAL CODE

EMAIL ADDRESS

example@example.com

GENDER?

For cancer patients: Are you currently undergoing cancer treatment?

YesNo

If Yes, do you have written permission from your treatment team to receive MLD at this time?

YesNo

The following information will be used to help plan safe and effective massage sessions. Please answer the questions to the best of your knowledge.

Have you been cleared by your doctor?

YesNo

Have you received surgery?

YesNo

If so, have you received MLD or any other massages after surgery?

YesNo

If Yes, how many sessions?

Please specify ALL surgeries/procedures*

Please specify which areas of the body you wish to be treated:

Please list all medications you are currently taking and reason for prescription

Depending on the medical condition(s) stated above, you may not be eligible for treatment.

This will be reviewed by you and your therapist before making a final decision.

In order to create the most beneficial session, please specify ALL current and previous medical conditions. Ex: Currently pregnant, Diabetes, Coronary heart disease, Hypo/Hyperthyroidism, Hypertension, etc...

I understand that the Manual Lymphatic Drainage and Post-op massage I receive is provided for the basic purpose of improving the flow of my lymphatic system and also for relaxation.

If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort.

I further understand that massage or bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or another qualified medical specialist for any mental or physical ailment of which I am aware.

I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness and that nothing said in the course of the session given should be construed as such. Because massage/ bodywork should not be performed under certain medical conditions,

I affirm that I have stated all my known medical conditions and answered all questions honestly.

I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner's part should I fail to do so.

*Please Note: Manual Lymphatic Drainage (MLD) is a very powerful modality and certain medical conditions are contraindicated and determine if or when you can receive a session. After the consultation and review of the information you have provided on this form, it will be determined if MLD should be administered to you today. Some conditions will require a note from your doctor before proceeding. Please understand this is for your safety and well-being.

Signature

Today's date

Date

Please read through drop down menu and choose option accordingly.

SIGNATURE

DATE

Date

Manual Lymphatic Drainage - Intake form

Body Verb - Michell Rodriguez RN

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