Manual Lymphatic Drainage Client Intake Form
Heart of Healing Therapeutic Medical Massage,LLC
PERSONAL INFORMATION
Name
*
First Name
Last Name
Best phone number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
*
Employer
Email
*
example@example.com
Primary Physician
*
Emergency Contact / Relationshiop / Phone
*
How did you hear about us?
*
MEDICAL INFORMATION
Are you taking any medications?
*
yes
no
If yes, please list name and use
Are you currently pregnant?
*
yes
no
Do you suffer from chronic pain?
*
yes
no
If yes, please explain
Have you had any orthopedic injuries?
*
yes
no
If yes, please list
Have you had manual lymph drainage before?
*
yes
no
Do you have any allergies or sensitivities?
*
yes
no
If yes, please explain
What is your intention for this treatment session?
Please circle any areas of discomfort.
By signing below, you agree to the following: I have completed this form to the best of my ability and knowledge and agree to inform my therapist of any if the above information changes at any time.
Today's date
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Month
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Day
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Date
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