Manual Lymph Drainage Health History Form
Heart of Healing Therapeutic Medical Massage, LLC
Name
*
First Name
Last Name
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Check the following conditions that apply to you, past and present:
Muscular Skeletal
Headaches - Migraines
Head Trauma
Brain Surgery
Brain Tumor
Joint Stiffness / swelling
Spasms / Cramps
Broken / Fractured Bones
Strains / Sprains
Back, hip pain
Shoulder, neck arm and hand pain
Leg, foot pain
Chest, ribs, abdominal pain
Problems walking
Jaw pain / TMJ
Tendonitis
Bursitis
Arthritis
Osteoporosis
Scoliosis
Bone or joint disease
Herniated Disc
Sciatica
Joint replacement (s)
Other
Circulatory and Respiratory
Lymphedema
Edema
Dizziness
Shortness of breath
Fainting
Cold Feet or Hands
Cold Sweats
Swollen Ankles
Varicose Veins
Blood Clots
Stroke
Heart Condition
Allergies
Sinus problems
Asthma
High blood pressure
Low blood pressure
Other
Skin
Rashes or Acne
Allergies
Athletes Foot
Warts
Moles
Cosmetic Surgery
Break in skin
Other
Digestive
Acid Reflux
Nervous Stomach
Ulcers
Indigestion
Constipation
Intestinal gas / bloating
Diarrhea
Diverticulitis
Irritable bowel syndrome
Chohn's Disease
Colitis
Nausea
Other
Nervous System
Numbness / tingling
Fatigue
Chronic pain
Sleep difficulties
Neuropathy
Paralysis
Herpes / shingles
Cerebral Palsy
Epilepsy
Chronic Fatigue Syndrome
Multiple Sclerosis
Muscular Dystrophy
Parkinson's disease
Spinal cord injury
Other
Reproductive System
Currently Pregnant
Menopause
Endometriosis
Post-Menopause
Hysterectomy
Pelvic Inflammatory Disease
Fertility concerns
IUD
Other
Other
Cancer
Loss of appetite
Depression
Irritability
Vertigo
Tinnitus
Bladder infection
Diabetes
Fibromyalgia
HIV Positive
Other
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.
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Date
*
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Month
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Day
Year
Date
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