Domain

Cocoon Lymphatic Drainage & Massage

Health History Intake Questionnaire
Date

MonthDayYear
Date
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Alternate Phone
Email
example@example.com
Age
What is the main reason you seek lymphatic drainage?

As appropriate include description of

condition ONSET, AGGRAVATING FACTORS,

NIGHT PAIN, INJURIES AND ACCIDENTS.
Primary Complaint:
Surgery History, Radiotherapy
List your personal history of surgery, if any,

starting with the most recent.

Practitioner is NOT a physician, nurse, or physical therapist, and does not give medical advice.
Surgery and Radiation Therapy:
Medication, Chemotherapy
List all medications used currently, and

others used within 12 months, and reason
Medications:
Accidents and Injuries
List any major accidents starting with most
Major Accidents, Injury:
Lymphedema
Briefly describe any history of lymphedema. NOTE: An additional lymphedema evaluation is used.
Lymphedema History:
Congenital Conditions
Describe any congenital or physiological

conditions that you care to disclose
Congenital Conditions:
Allergies or Known Sensitivities
List all known allergies or sensitivities,

including skin reactions to massage lotions,
Allergies or Sensitivities:
Describe the Objective of Your Massage Therapy
Indicate both short-term and longer-term

objectives you would like to accomplish.
Desired Results / Objectives:
Check All that apply from any conditions below.
A. Nervous System

Frequent Anxiety / AngerIrritabilityDepressionMuscle WeaknessSciatica ProblemsParalysisNumbnessTinglingAbnormal SensationsEpilepsyFatigueFrequent sweatingOther
B. Skin

Frequent Skin InfectionsCellulitisItching/DrynessPsoriasis/eczemaSkin Disease/ConditionPlantar wartsWound/Open sore
C. Respiratory

Frequent Sore ThroatFrequent Coughs / ColdsSinus Irritation / Swollen GlandsPneumoniaEmphysemaAsthmaChronic BronchitisTuberculosisOther
D. Cardiovascular

Heart PalpitationsDizziness / FaintingThrombosisShortness of BreathHeart AttackRheumatic FeverHeart Disease / ConditionStrokeEdemaChest PainsAneurysmArteriosclerosisOther
E. Circulatory System

PhlebitisLow Blood PressureHigh Blood PressureAnemia/Blood DisorderHemophilia / Excessive BleedingBruise EasilyCurrently BruisedFrequent Cold Hands / FeetGoutVaricose veinsOther
F. Musculo-skeletal

Neck / Back PainRib PainAching Muscles / JointsLimited Joint MovementArtificial Joint / Steel PinsPainful / Swollen JointCracking in JointsPain When WalkingMuscle CrampsOsteoarthritisRheumatoid ArthritisPoor PostureBursitis/TendonitisFrozen ShoulderFracturesOther
G. Genito-urinary

Prostate ProblemsPainful / Frequent UrinationBladder InfectionKidney DisordersKidney StonesPainful MenstruationIrregular MenstruationPregnant (or possibility)Birth Control PillPelvic InfectionMenopauseOther
H. Head and Neck

Eye ProblemsMigranesFacial Nerve Pain / Bellʼs PalsyTorticollis GLThryoid ProblemsLumps in NeckNeck Tension / WhiplashEaraches / Ear InfectionsHeadacheOther
I. Digestive system

Poor AppetiteGas or BloatingConstipationDiarrheaIndigestionHemorrhoidsTiredness After MealsCravingsNausea / VomitingProblems SwallowingAbdominal PainHeartburnUlcerGallbladder TroubleAbdominal Cyst / TumorOther
J. General

AIDS/HIVInsomnia / Trouble SleepingCancerHerpesObesityDiabetes Type I / IIParkinsonʼsCerebral PalsyFibromyalgiaMultiple SclerosisComa / SeizuresLiver DisorderAcute FeverAcute InflammationAcute InfectionPolioOther
Please add any additional information that you feel I should know, more information is always better.
How did you find me?

Refer from a friendRefer from a surgeonGoogleFacebookYelpOther
Should be Empty:

Surgery History, Radiotherapy

Medication, Chemotherapy

Accidents and Injuries

Lymphedema

Congenital Conditions

Allergies or Known Sensitivities

Describe the Objective of Your Massage Therapy