• MLD Intake Form

    Manual Lymphatic Drainage intake for Massage with Annika. Please complete the screening, history, lifestyle, and consent sections.

  • Personal Information

  • Date of Birth*
     - -
  • Format: (000) 000-0000.

  • Reason for Visit & Goals

  • Have you had MLD before?*
  • Was it beneficial?

  • Contraindications

  • Contraindications present
  • Active infection
  • Fever
  • Cellulitis
  • Deep vein thrombosis (DVT)
  • Congestive heart failure
  • Kidney disease
  • Active cancer treatment
  • Shortness of breath
  • Recent vaccination

  • Medical Conditions

  • Heart disease*
  • Liver disease*
  • Diabetes*
  • Thyroid disorder*
  • Autoimmune condition*
  • Neurological condition*
  • Blood clotting disorder*
  • Blood pressure concerns*

  • Swelling & Lymphatic History

  • Do you have swelling or lymphatic issues?*
  • Lymphedema
  • Lipedema
  • Compression garments

  • Surgical History

  • Have you had any surgeries?*
  • Lymph node removal

  • Cancer History

  • History of cancer?*

  • Skin & Tissue Health

  • Skin and tissue conditions

  • Medications & Allergies

  • Currently taking any medications?*
  • Blood thinners*
  • Diuretics*
  • Steroids*

  • Lifestyle

  • Miscellaneous

  • How did you hear about me?

  • Consent & Signature

  • I understand that Manual Lymphatic Drainage is a complementary wellness service and is not a substitute for medical diagnosis or treatment.I understand that it is my responsibility to inform my practitioner of any changes in my health status. I have disclosed all known medical conditions relevant to my care.I voluntarily consent to receive Manual Lymphatic Drainage treatment.

  • Date*
     - -
  • Should be Empty: