Manual Lymphatic Drainage Paperwork

CLIENT INFORMATION:

Name: *

Today's Date: *

Home Phone Number:

Cell Phone Number: *

Email: *

Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Birthdate: *

Age: *

Referred by:

Name of Primary Care Physician: *

In Case of Emergency, please contact:

Layout

Emergency Contact Name: *

Relationship:

Emergency Contact Phone Number: *

PERSONAL HEALTH & HISTORY:

For what reason are you seeking Manual Lymphathic Drainage? *

Therapeutic
Medical Issue
Other

If you are here for a medical issue, when did the problem start?

Please describe your problem, including where it is and its severity:

List any medications you are taking, including hormones, vitamins, herbs, and nonprescription medications:

List any surgeries you have had, and their reason and approximate date:

Please mark all CURRENT symptoms:

General: *

Date of last cancer treament (if applicable):

Female Reproductive: *

Currently pregnant
Currently menstruating
Fibrocystic breast disease

Musculoskeletal: *

Osteoporosis
Arthritis

Ears, Nose, Throat: *

Ringing in ears
Sinus problems
Earaches

Skin: *

Rash
Moles
Major scars
Lumps

Cardiovascular: *

Other:

Hematologic/Lymphatic: *

Frequent bruises
Cuts that do not stop bleeding
Enlarged lymph nodes (glands)
Lymph nodes removed

Neurologic: *

Dizziness
Seizures

Gastrointestinal: *

Nausea
Abdominal pain

Urinary: *

Urinary tract infection
Kidney stones

Allergic: *

Please mark all PAST conditions:

Other:

Please include any information (medical or other) not specified on this intake form that you feel is important for the practitioner to know:

By checking the below box you confirm that you understand the below:

I understand the contraindications for MLD

PLEASE READ THROUGH THE FOLLOWING CONTRAINDICATIONS FOR MANUAL LYMPHATIC DRAINAGE BEFORE SIGNING OUR AGREEMENT AND RELEASE OF LIABILITY. If any of the below apply and you would like to cancel your appointment, please contact our Client Advocate. Contraindications for MLD: Chemotherapy (MLD can be done after two weeks of a completed Chemotherapy treatment); heart, kidney, or liver failure; malignant tumor; deep vein thrombosis; medically-diagnosed infection; open wounds; prescription blood thinners. Contraindications for Pregnancy MLD: High risk pregnancy; malignant tumor; acute inflammation; deep vein thrombosis; heart, kidney, or liver failure; kidney disease; morning sickness.

CLIENT CONSENT

Manual Lymphatic Drainage Informed Consent and Liability Release Form and Agreement and Release of Liability: *

Please click HERE to read our Manual Lymphatic Drainage Informed Consent and Liability Release Form and Agreement and Release of Liability. Then, sign by typing your full name in the box above. By signing, you are acknowledging that you have read and accept the terms and conditions of the Manual Lymphatic Drainage Informed Consent and Liability Release Form and Agreement and Release of Liability.

New Client Appointment Checklist

These guidelines are in place for your protection and ours, as we strive to serve you to the best of our ability.

Please understand the importance of keeping your appointments. We do have a 24 hour cancellation policy that is strictly enforced.

Please contact our Client Advocate if you have any questions or need additional information.

Contraindications

Is there anyone who should not use MLD?

New Client Form