Cocoon Lymphatic Drainage & Massage
Health History Intake Questionnaire
What is the main reason you seek lymphatic drainage?
As appropriate include description of
condition ONSET, AGGRAVATING FACTORS,
NIGHT PAIN, INJURIES AND ACCIDENTS.
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.
List all medications used currently, and
others used within 12 months, and reason
List any major accidents starting with most
Briefly describe any history of lymphedema. NOTE: An additional lymphedema evaluation is used.
Describe any congenital or physiological
conditions that you care to disclose
List all known allergies or sensitivities,
including skin reactions to massage lotions,
Indicate both short-term and longer-term
objectives you would like to accomplish.
Check All that apply from any conditions below.