Today’s Date
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name
First Name
Last Name
Date of Birth
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number (home)
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Area Code
Phone Number
Phone Number (work/cell)
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Area Code
Phone Number
Email
example@example.com
Occupation
Height
Weight
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone Number
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Area Code
Phone Number
Referred by
Who was your plastic/cosmetic surgeon?
Did your surgeon recommend post surgical MLD?
Yes
No
What procedures were preformed?
Have you been cleared by your doctor to receive MLD?
Yes
No
Have you had any previous surgeries? If yes, please list below.
If so, have you received MLD PostOp?
Yes
No
How many sessions have you received?
Are you experiencing any swelling or bruising?
Yes
No
Are you currently under the care of a physician, chiropractor, or alternative medicine practitioner? If so, what are you being treated for?
Please list any medications (prescription or non prescription), vitamins and supplements you are currently taking:
How frequently and for how long do you exercise and what do you do? Include sports Pilates, yoga, gardening and/or other physical activities.
On a scale from 1 to 10 (one being low and 10 being high) what is your stress level today?
On a scale from 1 to 10 (one being low and 10 being high) what is your emotional level today?
What are your expectations for your Post-Op Cosmetic Care?
Past/ Present Health conditions (place and X in any that apply to you in the past or present)
Rows
Present
Past
Headaches
Asthma
Cold hands/feet
Swollen ankles
Sinus Conditions
Frequent colds
Allergies
Loss of smell\Taste
Skin conditions
Painful back/swollen joints
Auto immune disorder
Cancer
Varicose veins
Blood clots\DVT
Heart problems
Pacemaker
High or low blood pressure
Diabetes
Epilepsy or seizures
Fainting spells
Pins and needles in arms legs hands or feet
Neurological problems
Spinal problems
Herniated or bulging discs
Osteoarthritis
Arthritis
Anxiety
Depression/Panic
Sleep disturbance
Loss of memory
Whiplash
Bruise easily
Constipation/diarrhea
Contact lenses
Dentures/partials
Hemorrhoids
Artificial/missing limbs
Muscular tension
Sciatica
Pregnant (How many weeks?)
I understand the treatment here is not a replacement for medical care.
As such, the therapist/practitioner does not prescribe medical treatment of pharmaceuticals, nor does she perform any spinal manipulations (unless specified under her scope of practice).
I understand that treatment is not a substitute for medical treatments and/or diagnoses and it is recommended that I see a qualified professional for any physical or mental conditions that I may have.
I have stated all my known conditions and take it upon myself to keep the therapist/practitioner updated on my health.
I understand that payment is due at the time of treatment unless arrangements have been made otherwise.
I agree to give at least 24 hours of notice of cancellation of appointment otherwise I will be expected to pay for the session.
Please initial below to confirm agreement to everything listed and entered on above form.
Please verify that you are human
*
Signature
DateTime
Submit
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