POST CARE INTAKE FORM- CONFIDENTIAL INFORMATION

POST SURGICAL MLD CLIENT INTAKE FORM - CONFIDENTIAL INFORMATION
WELCOME! would like your appointment to be pleasant and comfortable. Please let me know if you have any questions regarding your session.
Name
Date of Birth

MonthDayYear
Date
Address

Email Address

Street Address Line 2

CityState

Zip
Phone(H)
Occupation
Phone(C)
Emergency Contact (Name, #)
Have you received any lymphatic massage before
If Yes Date of Last massage

MonthDayYear
Date
Level of pressure you prefer ( light touch, moderate touch
What medical instructions are you following that your doctor requires?
What (if any) positions make you feel better?
Please indicate the areas in which you are feeling swelling/bruising/discomfort:
Answer
Please review this list. Those conditions that have affected your health recently or in the past.

SkinDigestive Allergies specifyIrritable Bowel syndrome Rashes / Eczema/ Psoriasis/AcneUlcerative colitis/Diverticulosis Celiac/Chron's disease Herpes/Cold sores Fungal infection /Athlete's foot/WartsUlcers Boils/Impetigo/LiceCirrhosis/Hepatitis (Liver) Skin cancer - specifyGallstones

Musculoskeletal Bone or joint disease/Gout Tendonitis/Bursitis/Jaw pain (TMJ)Pregnant: # WeeksTrimester Arthritis /Osteoarthritis/Rheumatoid: arthritis Ovarian / menstrual problems Fibromyalgia/Lupus /Lyme diseaseProstate specify Osteoporosis/Osteopenia

Spinal Problems/Disc diseaseNervous System Spondylosis/Ankylosing SpondylitisPeripheral neuropathy Carpel Tunnel/Thoracicoutlet syndrome Pinched nerve / Numbness / Tingling Plantar fasciitis Parkinson disease/Tremor Marfan / Ehlers-Danlos syndromeAnxiety disorder / Depression /Eating disorder Headaches/Migraines/Seizure disorder RespiratorySleep disorder / Chronic Fatigue syndrome Asthma/Emphysema/Breathing difficultyBalance disorder Cold/Flu/Pneumonia Shingles Bronchitis/Sinusitis

Allergies/ Cancer /tumors: Lung Cancer Other:Bladder/Kidney ailment Diabetes Circulatory/Immune Heart Condition /Congestive Heart FailureChronic Pain Phlebitis/Varicose Veins Drug use Blood Clots/ Thrombosis (DVT)/ EmbolismAlcohol use High/ Low Blood PressureCaffeine/Tobaccouse Lymphedema/EdemaStress Contact lenses (hard or soft) Fever
List any conditions here:
2020 Updated Post Surgical MLD Intake Form2
POST SURGICAL MANUAL LYMPAHTIC DRAINAGE (MLD) INTAKE FORM (all information is confidential) Welcome. A few questions about your surgery and previous aftercare experience will assist us in providing you the best possible care.
HOW DID YOU HEAR ABOUT Justified by Netta LLC?
DATE OF SURGERY

MonthDayYear
Date
LOCATION OF SURGERY:
Answer
SURGEON'S NAME:
LAST
FIRST
ON A SCALE OF 1 to 10, HOW WOULD YOU RATE YOUR SURGEON?
PROCEDURES? (please list all):
Answer
IF LIPOSUCTION, IN WHAT AREAS?
Answer
WERE DRAINS USED FOLLOWING PROCEDURE? IF YES, ARE DRAINS CURRENTLY IN? ARE ALL INCISIONS HEALED?
Answer
HAS ANY FLUID NEEDED TO BE REMOVED WITH NEEDLES/SYRINGES?
IF YES, HOW OFTEN?
DID YOU STAY AT A RECOVERY HOUSE?
IF so, FOR HOW LONG?
HOW MANY MASSAGE SESSIONS DID YOU HAVE?
WHAT STAGE COMPRESSION GARMET ARE YOU CURRENTLY IN?
Answer
ARE YOU CURRENTLY EXPERIENCING PAIN?
IF YES, WHERE?
ARE YOU CURRENTLY EXPERIENCING SWELLING?
IF YES, WHERE?
DO YOU NOTICE THICKENED OR FIBROTIC AREAS ANYWHERE?
ANY OTHER SYMPTOMS?
Please provide additional details:

Your signature below indicates that you understand and abide by our Pay in Full, No Show and Late Cancel Policies. A $25 fee will be charged for No Shows and cancellations of less than 24 hrs.

PLEASE READ THE FOLLOWING INFORMATION AND SIGN BELOW:

Iunderstand that the massage/bodywork I receive is provided for the basic purpose of relaxation and relief of muscular tension. If experience any pain or discomfort during the session, 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/bodywork : should not be construed as a substitute for medical examination, diagnosis, or treatment and that should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment that am aware of. 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, affirm that have stated all my known medical conditions and answered all questions honestly. 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 fail to do so. also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session. and will be liable for payment of the scheduled appointment
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

POST SURGICAL MLD CLIENT INTAKE FORM - CONFIDENTIAL INFORMATION

LOCATION OF SURGERY:

SURGEON'S NAME:

IF LIPOSUCTION, IN WHAT AREAS?

WERE DRAINS USED FOLLOWING PROCEDURE? IF YES, ARE DRAINS CURRENTLY IN? ARE ALL INCISIONS HEALED?

HAS ANY FLUID NEEDED TO BE REMOVED WITH NEEDLES/SYRINGES?

DID YOU STAY AT A RECOVERY HOUSE?

WHAT STAGE COMPRESSION GARMET ARE YOU CURRENTLY IN?

ARE YOU CURRENTLY EXPERIENCING PAIN?

ARE YOU CURRENTLY EXPERIENCING SWELLING?

DO YOU NOTICE THICKENED OR FIBROTIC AREAS ANYWHERE?