Manual Lymph Drainage Health History Form

Manual Lymph Drainage Health History Form

Heart of Healing Therapeutic Medical Massage, LLC
Name*

First NameLast Name
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Check the following conditions that apply to you, past and present:
LymphedemaEdemaDizzinessShortness of breathFaintingCold Feet or HandsCold SweatsSwollen AnklesVaricose VeinsBlood ClotsStrokeHeart ConditionAllergiesSinus problemsAsthmaHigh blood pressureLow blood pressureOther
Rashes or AcneAllergiesAthletes FootWartsMolesCosmetic SurgeryBreak in skinOther
Acid RefluxNervous StomachUlcersIndigestionConstipationIntestinal gas / bloatingDiarrheaDiverticulitisIrritable bowel syndromeChohn's DiseaseColitisNauseaOther
Numbness / tinglingFatigueChronic painSleep difficultiesNeuropathyParalysisHerpes / shinglesCerebral PalsyEpilepsyChronic Fatigue SyndromeMultiple SclerosisMuscular DystrophyParkinson's diseaseSpinal cord injuryOther
Currently PregnantMenopauseEndometriosisPost-MenopauseHysterectomyPelvic Inflammatory DiseaseFertility concernsIUDOther
CancerLoss of appetiteDepressionIrritabilityVertigoTinnitusBladder infectionDiabetesFibromyalgiaHIV PositiveOther
By signing below, I agree to the following: I have completed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at any time. *
Date*

MonthDayYear
Date
Manual Lymph Drainage Health History Form

Heart of Healing Therapeutic Medical Massage, LLC
Headaches - MigrainesHead TraumaBrain SurgeryBrain TumorJoint Stiffness / swellingSpasms / CrampsBroken / Fractured BonesStrains / SprainsBack, hip painShoulder, neck arm and hand painLeg, foot painChest, ribs, abdominal painProblems walkingJaw pain / TMJTendonitisBursitisArthritisOsteoporosisScoliosisBone or joint diseaseHerniated DiscSciaticaJoint replacement (s)Other
Should be Empty: