Manual Lymphatic Drainage / Post-Op Intake Form
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Email
example@example.com
Birthday
-
Month
-
Day
Year
Phone Number
Please enter a valid phone number.
Gender
Please Select
Female
Male
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
In Case of Emergency
First Name
Last Name
Phone Number
Please enter a valid phone number.
Name of Primary Care Physician and Clinic:
For what reason are you seeking Manual Lymphatic Drainage?
Medical reason
Relaxation
If you are here for a medical issue, when did the problem start?
Please describe your problem including where it is and its severity.
Medical Background
Please check all affected areas.
GENERAL
Fever
Undergoing cancer treatment
Last chemotherapy session
Arteriosclerosis
Carotid sinus issues
Hyperthyroidism
Liver Cirrhosis
Other
FEMALE REPRODUCTIVE
Currently pregnant
Currently menstruating
Fibrocystic breast disease
IUD
Other
EAR , NOSE THROAT
Ringing in ears
Sinus problems
Arteriosclerosis
Earaches
Other
SKIN
Cellulitis
Rash
Major scars
Lumps
Other
MUSCOLOSKELETAL
Osteoporosis
Osteoarthritis
Hernia
Rheumatoid arthritis
Other
HEMATOLOGIC/LYMPHATIC
Cuts that do not stop bleeding
Enlarged lymph nodes (glands)
Lymph nodes removed
Frequent bruising
HIV/AIDS:
Other
CARDIOVASCULAR
Chest pain or pressure
Swelling of legs
Palpitations
Varicose veins
Dizziness
Acute deep vein thrombosis
Congestive heart failure
Heart attack
High/Low blood pressure
Aneurysm
Cardiac arrhythmia
Other
GASTRO INTESTINAL
Crohn’s disease
Abdominal pain
Surgical implant(mesh or other)
GI inflammation
Diverticulitis/Diverticulosis:
Other
NEUROLOGICAL
Strokes
Seizures
Other
ALLERGIES
Ear fullness
Sinus congestion
Recent sinus surgery
Other
URINARY
Kidney failure
Kidney stones
Urinary tract infection
Dialysis
Other
EMOTIONAL
Stress
Anxiety
Difficulty sleeping
Depression
Other
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Please list all surgeries (including Cesarean section).
Surgery
Date
Hospital and Surgeon
1
2
3
4
5
6
7
8
9
10
Please list all medications (including vitamins, hormones, and herbs) and reason for prescription.
Medications
Reason
2
3
4
5
Is there is anything else that your MLD therapist should know about you or your needs before the session?
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Acknowledgement
*
I understand that the Manual Lymphatic Drainage 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 other 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.
I,
blanks
the client, have (please check both boxes below)
Completely read this consent form
Been thoroughly explained and fully understand the information given in this consent form
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Please Note:
Manual Lymphatic Drainage (MLD) is a very powerful modality and certain medical conditions are contraindicated and determine if and 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.
Clients Name
First Name
Last Name
Signature
Date Signed
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Month
-
Day
Year
Date
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