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MANUAL LYMPHATIC DRAINAGE INTAKE FORM 

I understand that the Manual Lymphatic Drainage I receive is provided for the basic purpose of improving the flow of my lymphatic system and also for relaxation. If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort.

I further understand that massage or bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such.

Because massage/ bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so.

*Please Note: Manual Lymphatic Drainage (MLD) is a very powerful modality and certain medical conditions are contraindicated and determine if and when you can receive a session. After the consultation and review of the information you have provided on this form, it will be determined if MLD should be administered to you today. Some conditions will require a note from your doctor before proceeding. Please understand this is for your safety and well-being. 

Today’s Date: April 16, 2024

First Client's Name

First Name*

Last Name*
First Client's Date of Birth*
First Client's Information

Primary Care Physician and Clinic:
For what reason are you seeking Manual Lymphatic Drainage?
Medical reason
Relaxation

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

Please describe your problem including where it is and its severity.

Please mark all current and previous conditions that apply

General
Fever

Since when?

Under treatment?
Cancer
Present
past

Where?

Last treatment date:
Undergoing cancer treatment

Last chemotherapy session

Last radio session

Additional info may be needed 

Arteriosclerosis
Carotid sinus issues
Hyperthyroidism
Liver Cirrhosis
Other

Other:
Ears, Nose, Throat
Ringing in ears
Sinus problems
Earaches
Other

Other:
Cardiovascular
Congestive heart failure
Treated?*
No
Yes

When?

Under treatment?
Acute deep vein thrombosis
Treated?*
No
Yes

When?

Under treatment?
Blood clots?
Treated? *
No
Yes

When?

Under treatment?
Chest pain or pressure
Swelling of legs
Palpitations
Varicose veins
Dizziness
Heart attack
High/Low blood pressure
Aneurysm
Cardiac arrhythmia
Other

Other:
Gastro-Intestinal
Crohn’s disease
Abdominal pain
Surgical implant (mesh or other)
GI inflammation
Diverticulitis/Diverticulosis:
Other

Other:
Urinary
Kidney failure
Dialysis?

Under treatment?
Kidney disease?

What?

When?

Under treatment?
Kidney stones
Urinary tract infection
Dialysis
Other

Other:
Female Reproductive
Currently pregnant
Currently menstruating
Fibrocystic breast disease
IUD
Other

If any of the above is checked, please explain:

Other:
Musculoskeletal
Osteoporosis
Osteoarthritis
Hernia
Rheumatoid arthritis
Other

Other:
Skin
Cellulitis-acute
not acute
Treated?*
No
Yes

When?

Under treatment?
Rash
Major scars
Lumps
Other

If any of the above is checked, please explain:

Other:
Hematologic/ Lymphatic
Cuts that do not stop bleeding
Enlarged lymph nodes (glands)
Lymph nodes removed
Frequent bruising
HIV/AIDS:
Other

Other:
Neurological
Strokes
Seizures
Other

Other:
Allergies
Ear fullness
Sinus congestion
Recent sinus surgery
Other

Other:
Emotional
Stress
Anxiety
Difficulty sleeping
Depression
Other

Other:

Please list all surgeries (including Cesarean section). 


Surgery

Date

City

Please list all medications (including vitamins, hormones, and herbs) and reason for prescription. 


Medication

Reason

Is there is anything else that we should know about you or your needs before the session?
First Client's Signature*
Second Client's Name

First Name*

Last Name*
Second Client's Date of Birth*
Second Client's Information

Primary Care Physician and Clinic:
For what reason are you seeking Manual Lymphatic Drainage?
Medical reason
Relaxation

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

Please describe your problem including where it is and its severity.

Please mark all current and previous conditions that apply

General
Fever

Since when?

Under treatment?
Cancer
Present
past

Where?

Last treatment date:
Undergoing cancer treatment

Last chemotherapy session

Last radio session

Additional info may be needed 

Arteriosclerosis
Carotid sinus issues
Hyperthyroidism
Liver Cirrhosis
Other

Other:
Ears, Nose, Throat
Ringing in ears
Sinus problems
Earaches
Other

Other:
Cardiovascular
Congestive heart failure
Treated?*
No
Yes

When?

Under treatment?
Acute deep vein thrombosis
Treated?*
No
Yes

When?

Under treatment?
Blood clots?
Treated? *
No
Yes

When?

Under treatment?
Chest pain or pressure
Swelling of legs
Palpitations
Varicose veins
Dizziness
Heart attack
High/Low blood pressure
Aneurysm
Cardiac arrhythmia
Other

Other:
Gastro-Intestinal
Crohn’s disease
Abdominal pain
Surgical implant (mesh or other)
GI inflammation
Diverticulitis/Diverticulosis:
Other

Other:
Urinary
Kidney failure
Dialysis?

Under treatment?
Kidney disease?

What?

When?

Under treatment?
Kidney stones
Urinary tract infection
Dialysis
Other

Other:
Female Reproductive
Currently pregnant
Currently menstruating
Fibrocystic breast disease
IUD
Other

If any of the above is checked, please explain:

Other:
Musculoskeletal
Osteoporosis
Osteoarthritis
Hernia
Rheumatoid arthritis
Other

Other:
Skin
Cellulitis-acute
not acute
Treated?*
No
Yes

When?

Under treatment?
Rash
Major scars
Lumps
Other

If any of the above is checked, please explain:

Other:
Hematologic/ Lymphatic
Cuts that do not stop bleeding
Enlarged lymph nodes (glands)
Lymph nodes removed
Frequent bruising
HIV/AIDS:
Other

Other:
Neurological
Strokes
Seizures
Other

Other:
Allergies
Ear fullness
Sinus congestion
Recent sinus surgery
Other

Other:
Emotional
Stress
Anxiety
Difficulty sleeping
Depression
Other

Other:

Please list all surgeries (including Cesarean section). 


Surgery

Date

City

Please list all medications (including vitamins, hormones, and herbs) and reason for prescription. 


Medication

Reason

Is there is anything else that we should know about you or your needs before the session?
Third Client's Name

First Name*

Last Name*
Third Client's Date of Birth*
Third Client's Information

Primary Care Physician and Clinic:
For what reason are you seeking Manual Lymphatic Drainage?
Medical reason
Relaxation

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

Please describe your problem including where it is and its severity.

Please mark all current and previous conditions that apply

General
Fever

Since when?

Under treatment?
Cancer
Present
past

Where?

Last treatment date:
Undergoing cancer treatment

Last chemotherapy session

Last radio session

Additional info may be needed 

Arteriosclerosis
Carotid sinus issues
Hyperthyroidism
Liver Cirrhosis
Other

Other:
Ears, Nose, Throat
Ringing in ears
Sinus problems
Earaches
Other

Other:
Cardiovascular
Congestive heart failure
Treated?*
No
Yes

When?

Under treatment?
Acute deep vein thrombosis
Treated?*
No
Yes

When?

Under treatment?
Blood clots?
Treated? *
No
Yes

When?

Under treatment?
Chest pain or pressure
Swelling of legs
Palpitations
Varicose veins
Dizziness
Heart attack
High/Low blood pressure
Aneurysm
Cardiac arrhythmia
Other

Other:
Gastro-Intestinal
Crohn’s disease
Abdominal pain
Surgical implant (mesh or other)
GI inflammation
Diverticulitis/Diverticulosis:
Other

Other:
Urinary
Kidney failure
Dialysis?

Under treatment?
Kidney disease?

What?

When?

Under treatment?
Kidney stones
Urinary tract infection
Dialysis
Other

Other:
Female Reproductive
Currently pregnant
Currently menstruating
Fibrocystic breast disease
IUD
Other

If any of the above is checked, please explain:

Other:
Musculoskeletal
Osteoporosis
Osteoarthritis
Hernia
Rheumatoid arthritis
Other

Other:
Skin
Cellulitis-acute
not acute
Treated?*
No
Yes

When?

Under treatment?
Rash
Major scars
Lumps
Other

If any of the above is checked, please explain:

Other:
Hematologic/ Lymphatic
Cuts that do not stop bleeding
Enlarged lymph nodes (glands)
Lymph nodes removed
Frequent bruising
HIV/AIDS:
Other

Other:
Neurological
Strokes
Seizures
Other

Other:
Allergies
Ear fullness
Sinus congestion
Recent sinus surgery
Other

Other:
Emotional
Stress
Anxiety
Difficulty sleeping
Depression
Other

Other:

Please list all surgeries (including Cesarean section). 


Surgery

Date

City

Please list all medications (including vitamins, hormones, and herbs) and reason for prescription. 


Medication

Reason

Is there is anything else that we should know about you or your needs before the session?
Fourth Client's Name

First Name*

Last Name*
Fourth Client's Date of Birth*
Fourth Client's Information

Primary Care Physician and Clinic:
For what reason are you seeking Manual Lymphatic Drainage?
Medical reason
Relaxation

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

Please describe your problem including where it is and its severity.

Please mark all current and previous conditions that apply

General
Fever

Since when?

Under treatment?
Cancer
Present
past

Where?

Last treatment date:
Undergoing cancer treatment

Last chemotherapy session

Last radio session

Additional info may be needed 

Arteriosclerosis
Carotid sinus issues
Hyperthyroidism
Liver Cirrhosis
Other

Other:
Ears, Nose, Throat
Ringing in ears
Sinus problems
Earaches
Other

Other:
Cardiovascular
Congestive heart failure
Treated?*
No
Yes

When?

Under treatment?
Acute deep vein thrombosis
Treated?*
No
Yes

When?

Under treatment?
Blood clots?
Treated? *
No
Yes

When?

Under treatment?
Chest pain or pressure
Swelling of legs
Palpitations
Varicose veins
Dizziness
Heart attack
High/Low blood pressure
Aneurysm
Cardiac arrhythmia
Other

Other:
Gastro-Intestinal
Crohn’s disease
Abdominal pain
Surgical implant (mesh or other)
GI inflammation
Diverticulitis/Diverticulosis:
Other

Other:
Urinary
Kidney failure
Dialysis?

Under treatment?
Kidney disease?

What?

When?

Under treatment?
Kidney stones
Urinary tract infection
Dialysis
Other

Other:
Female Reproductive
Currently pregnant
Currently menstruating
Fibrocystic breast disease
IUD
Other

If any of the above is checked, please explain:

Other:
Musculoskeletal
Osteoporosis
Osteoarthritis
Hernia
Rheumatoid arthritis
Other

Other:
Skin
Cellulitis-acute
not acute
Treated?*
No
Yes

When?

Under treatment?
Rash
Major scars
Lumps
Other

If any of the above is checked, please explain:

Other:
Hematologic/ Lymphatic
Cuts that do not stop bleeding
Enlarged lymph nodes (glands)
Lymph nodes removed
Frequent bruising
HIV/AIDS:
Other

Other:
Neurological
Strokes
Seizures
Other

Other:
Allergies
Ear fullness
Sinus congestion
Recent sinus surgery
Other

Other:
Emotional
Stress
Anxiety
Difficulty sleeping
Depression
Other

Other:

Please list all surgeries (including Cesarean section). 


Surgery

Date

City

Please list all medications (including vitamins, hormones, and herbs) and reason for prescription. 


Medication

Reason

Is there is anything else that we should know about you or your needs before the session?
Fifth Client's Name

First Name*

Last Name*
Fifth Client's Date of Birth*
Fifth Client's Information

Primary Care Physician and Clinic:
For what reason are you seeking Manual Lymphatic Drainage?
Medical reason
Relaxation

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

Please describe your problem including where it is and its severity.

Please mark all current and previous conditions that apply

General
Fever

Since when?

Under treatment?
Cancer
Present
past

Where?

Last treatment date:
Undergoing cancer treatment

Last chemotherapy session

Last radio session

Additional info may be needed 

Arteriosclerosis
Carotid sinus issues
Hyperthyroidism
Liver Cirrhosis
Other

Other:
Ears, Nose, Throat
Ringing in ears
Sinus problems
Earaches
Other

Other:
Cardiovascular
Congestive heart failure
Treated?*
No
Yes

When?

Under treatment?
Acute deep vein thrombosis
Treated?*
No
Yes

When?

Under treatment?
Blood clots?
Treated? *
No
Yes

When?

Under treatment?
Chest pain or pressure
Swelling of legs
Palpitations
Varicose veins
Dizziness
Heart attack
High/Low blood pressure
Aneurysm
Cardiac arrhythmia
Other

Other:
Gastro-Intestinal
Crohn’s disease
Abdominal pain
Surgical implant (mesh or other)
GI inflammation
Diverticulitis/Diverticulosis:
Other

Other:
Urinary
Kidney failure
Dialysis?

Under treatment?
Kidney disease?

What?

When?

Under treatment?
Kidney stones
Urinary tract infection
Dialysis
Other

Other:
Female Reproductive
Currently pregnant
Currently menstruating
Fibrocystic breast disease
IUD
Other

If any of the above is checked, please explain:

Other:
Musculoskeletal
Osteoporosis
Osteoarthritis
Hernia
Rheumatoid arthritis
Other

Other:
Skin
Cellulitis-acute
not acute
Treated?*
No
Yes

When?

Under treatment?
Rash
Major scars
Lumps
Other

If any of the above is checked, please explain:

Other:
Hematologic/ Lymphatic
Cuts that do not stop bleeding
Enlarged lymph nodes (glands)
Lymph nodes removed
Frequent bruising
HIV/AIDS:
Other

Other:
Neurological
Strokes
Seizures
Other

Other:
Allergies
Ear fullness
Sinus congestion
Recent sinus surgery
Other

Other:
Emotional
Stress
Anxiety
Difficulty sleeping
Depression
Other

Other:

Please list all surgeries (including Cesarean section). 


Surgery

Date

City

Please list all medications (including vitamins, hormones, and herbs) and reason for prescription. 


Medication

Reason

Is there is anything else that we should know about you or your needs before the session?
Sixth Client's Name

First Name*

Last Name*
Sixth Client's Date of Birth*
Sixth Client's Information

Primary Care Physician and Clinic:
For what reason are you seeking Manual Lymphatic Drainage?
Medical reason
Relaxation

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

Please describe your problem including where it is and its severity.

Please mark all current and previous conditions that apply

General
Fever

Since when?

Under treatment?
Cancer
Present
past

Where?

Last treatment date:
Undergoing cancer treatment

Last chemotherapy session

Last radio session

Additional info may be needed 

Arteriosclerosis
Carotid sinus issues
Hyperthyroidism
Liver Cirrhosis
Other

Other:
Ears, Nose, Throat
Ringing in ears
Sinus problems
Earaches
Other

Other:
Cardiovascular
Congestive heart failure
Treated?*
No
Yes

When?

Under treatment?
Acute deep vein thrombosis
Treated?*
No
Yes

When?

Under treatment?
Blood clots?
Treated? *
No
Yes

When?

Under treatment?
Chest pain or pressure
Swelling of legs
Palpitations
Varicose veins
Dizziness
Heart attack
High/Low blood pressure
Aneurysm
Cardiac arrhythmia
Other

Other:
Gastro-Intestinal
Crohn’s disease
Abdominal pain
Surgical implant (mesh or other)
GI inflammation
Diverticulitis/Diverticulosis:
Other

Other:
Urinary
Kidney failure
Dialysis?

Under treatment?
Kidney disease?

What?

When?

Under treatment?
Kidney stones
Urinary tract infection
Dialysis
Other

Other:
Female Reproductive
Currently pregnant
Currently menstruating
Fibrocystic breast disease
IUD
Other

If any of the above is checked, please explain:

Other:
Musculoskeletal
Osteoporosis
Osteoarthritis
Hernia
Rheumatoid arthritis
Other

Other:
Skin
Cellulitis-acute
not acute
Treated?*
No
Yes

When?

Under treatment?
Rash
Major scars
Lumps
Other

If any of the above is checked, please explain:

Other:
Hematologic/ Lymphatic
Cuts that do not stop bleeding
Enlarged lymph nodes (glands)
Lymph nodes removed
Frequent bruising
HIV/AIDS:
Other

Other:
Neurological
Strokes
Seizures
Other

Other:
Allergies
Ear fullness
Sinus congestion
Recent sinus surgery
Other

Other:
Emotional
Stress
Anxiety
Difficulty sleeping
Depression
Other

Other:

Please list all surgeries (including Cesarean section). 


Surgery

Date

City

Please list all medications (including vitamins, hormones, and herbs) and reason for prescription. 


Medication

Reason

Is there is anything else that we should know about you or your needs before the session?
Seventh Client's Name

First Name*

Last Name*
Seventh Client's Date of Birth*
Seventh Client's Information

Primary Care Physician and Clinic:
For what reason are you seeking Manual Lymphatic Drainage?
Medical reason
Relaxation

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

Please describe your problem including where it is and its severity.

Please mark all current and previous conditions that apply

General
Fever

Since when?

Under treatment?
Cancer
Present
past

Where?

Last treatment date:
Undergoing cancer treatment

Last chemotherapy session

Last radio session

Additional info may be needed 

Arteriosclerosis
Carotid sinus issues
Hyperthyroidism
Liver Cirrhosis
Other

Other:
Ears, Nose, Throat
Ringing in ears
Sinus problems
Earaches
Other

Other:
Cardiovascular
Congestive heart failure
Treated?*
No
Yes

When?

Under treatment?
Acute deep vein thrombosis
Treated?*
No
Yes

When?

Under treatment?
Blood clots?
Treated? *
No
Yes

When?

Under treatment?
Chest pain or pressure
Swelling of legs
Palpitations
Varicose veins
Dizziness
Heart attack
High/Low blood pressure
Aneurysm
Cardiac arrhythmia
Other

Other:
Gastro-Intestinal
Crohn’s disease
Abdominal pain
Surgical implant (mesh or other)
GI inflammation
Diverticulitis/Diverticulosis:
Other

Other:
Urinary
Kidney failure
Dialysis?

Under treatment?
Kidney disease?

What?

When?

Under treatment?
Kidney stones
Urinary tract infection
Dialysis
Other

Other:
Female Reproductive
Currently pregnant
Currently menstruating
Fibrocystic breast disease
IUD
Other

If any of the above is checked, please explain:

Other:
Musculoskeletal
Osteoporosis
Osteoarthritis
Hernia
Rheumatoid arthritis
Other

Other:
Skin
Cellulitis-acute
not acute
Treated?*
No
Yes

When?

Under treatment?
Rash
Major scars
Lumps
Other

If any of the above is checked, please explain:

Other:
Hematologic/ Lymphatic
Cuts that do not stop bleeding
Enlarged lymph nodes (glands)
Lymph nodes removed
Frequent bruising
HIV/AIDS:
Other

Other:
Neurological
Strokes
Seizures
Other

Other:
Allergies
Ear fullness
Sinus congestion
Recent sinus surgery
Other

Other:
Emotional
Stress
Anxiety
Difficulty sleeping
Depression
Other

Other:

Please list all surgeries (including Cesarean section). 


Surgery

Date

City

Please list all medications (including vitamins, hormones, and herbs) and reason for prescription. 


Medication

Reason

Is there is anything else that we should know about you or your needs before the session?
Eighth Client's Name

First Name*

Last Name*
Eighth Client's Date of Birth*
Eighth Client's Information

Primary Care Physician and Clinic:
For what reason are you seeking Manual Lymphatic Drainage?
Medical reason
Relaxation

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

Please describe your problem including where it is and its severity.

Please mark all current and previous conditions that apply

General
Fever

Since when?

Under treatment?
Cancer
Present
past

Where?

Last treatment date:
Undergoing cancer treatment

Last chemotherapy session

Last radio session

Additional info may be needed 

Arteriosclerosis
Carotid sinus issues
Hyperthyroidism
Liver Cirrhosis
Other

Other:
Ears, Nose, Throat
Ringing in ears
Sinus problems
Earaches
Other

Other:
Cardiovascular
Congestive heart failure
Treated?*
No
Yes

When?

Under treatment?
Acute deep vein thrombosis
Treated?*
No
Yes

When?

Under treatment?
Blood clots?
Treated? *
No
Yes

When?

Under treatment?
Chest pain or pressure
Swelling of legs
Palpitations
Varicose veins
Dizziness
Heart attack
High/Low blood pressure
Aneurysm
Cardiac arrhythmia
Other

Other:
Gastro-Intestinal
Crohn’s disease
Abdominal pain
Surgical implant (mesh or other)
GI inflammation
Diverticulitis/Diverticulosis:
Other

Other:
Urinary
Kidney failure
Dialysis?

Under treatment?
Kidney disease?

What?

When?

Under treatment?
Kidney stones
Urinary tract infection
Dialysis
Other

Other:
Female Reproductive
Currently pregnant
Currently menstruating
Fibrocystic breast disease
IUD
Other

If any of the above is checked, please explain:

Other:
Musculoskeletal
Osteoporosis
Osteoarthritis
Hernia
Rheumatoid arthritis
Other

Other:
Skin
Cellulitis-acute
not acute
Treated?*
No
Yes

When?

Under treatment?
Rash
Major scars
Lumps
Other

If any of the above is checked, please explain:

Other:
Hematologic/ Lymphatic
Cuts that do not stop bleeding
Enlarged lymph nodes (glands)
Lymph nodes removed
Frequent bruising
HIV/AIDS:
Other

Other:
Neurological
Strokes
Seizures
Other

Other:
Allergies
Ear fullness
Sinus congestion
Recent sinus surgery
Other

Other:
Emotional
Stress
Anxiety
Difficulty sleeping
Depression
Other

Other:

Please list all surgeries (including Cesarean section). 


Surgery

Date

City

Please list all medications (including vitamins, hormones, and herbs) and reason for prescription. 


Medication

Reason

Is there is anything else that we should know about you or your needs before the session?
Ninth Client's Name

First Name*

Last Name*
Ninth Client's Date of Birth*
Ninth Client's Information

Primary Care Physician and Clinic:
For what reason are you seeking Manual Lymphatic Drainage?
Medical reason
Relaxation

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

Please describe your problem including where it is and its severity.

Please mark all current and previous conditions that apply

General
Fever

Since when?

Under treatment?
Cancer
Present
past

Where?

Last treatment date:
Undergoing cancer treatment

Last chemotherapy session

Last radio session

Additional info may be needed 

Arteriosclerosis
Carotid sinus issues
Hyperthyroidism
Liver Cirrhosis
Other

Other:
Ears, Nose, Throat
Ringing in ears
Sinus problems
Earaches
Other

Other:
Cardiovascular
Congestive heart failure
Treated?*
No
Yes

When?

Under treatment?
Acute deep vein thrombosis
Treated?*
No
Yes

When?

Under treatment?
Blood clots?
Treated? *
No
Yes

When?

Under treatment?
Chest pain or pressure
Swelling of legs
Palpitations
Varicose veins
Dizziness
Heart attack
High/Low blood pressure
Aneurysm
Cardiac arrhythmia
Other

Other:
Gastro-Intestinal
Crohn’s disease
Abdominal pain
Surgical implant (mesh or other)
GI inflammation
Diverticulitis/Diverticulosis:
Other

Other:
Urinary
Kidney failure
Dialysis?

Under treatment?
Kidney disease?

What?

When?

Under treatment?
Kidney stones
Urinary tract infection
Dialysis
Other

Other:
Female Reproductive
Currently pregnant
Currently menstruating
Fibrocystic breast disease
IUD
Other

If any of the above is checked, please explain:

Other:
Musculoskeletal
Osteoporosis
Osteoarthritis
Hernia
Rheumatoid arthritis
Other

Other:
Skin
Cellulitis-acute
not acute
Treated?*
No
Yes

When?

Under treatment?
Rash
Major scars
Lumps
Other

If any of the above is checked, please explain:

Other:
Hematologic/ Lymphatic
Cuts that do not stop bleeding
Enlarged lymph nodes (glands)
Lymph nodes removed
Frequent bruising
HIV/AIDS:
Other

Other:
Neurological
Strokes
Seizures
Other

Other:
Allergies
Ear fullness
Sinus congestion
Recent sinus surgery
Other

Other:
Emotional
Stress
Anxiety
Difficulty sleeping
Depression
Other

Other:

Please list all surgeries (including Cesarean section). 


Surgery

Date

City

Please list all medications (including vitamins, hormones, and herbs) and reason for prescription. 


Medication

Reason

Is there is anything else that we should know about you or your needs before the session?
Tenth Client's Name

First Name*

Last Name*
Tenth Client's Date of Birth*
Tenth Client's Information

Primary Care Physician and Clinic:
For what reason are you seeking Manual Lymphatic Drainage?
Medical reason
Relaxation

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

Please describe your problem including where it is and its severity.

Please mark all current and previous conditions that apply

General
Fever

Since when?

Under treatment?
Cancer
Present
past

Where?

Last treatment date:
Undergoing cancer treatment

Last chemotherapy session

Last radio session

Additional info may be needed 

Arteriosclerosis
Carotid sinus issues
Hyperthyroidism
Liver Cirrhosis
Other

Other:
Ears, Nose, Throat
Ringing in ears
Sinus problems
Earaches
Other

Other:
Cardiovascular
Congestive heart failure
Treated?*
No
Yes

When?

Under treatment?
Acute deep vein thrombosis
Treated?*
No
Yes

When?

Under treatment?
Blood clots?
Treated? *
No
Yes

When?

Under treatment?
Chest pain or pressure
Swelling of legs
Palpitations
Varicose veins
Dizziness
Heart attack
High/Low blood pressure
Aneurysm
Cardiac arrhythmia
Other

Other:
Gastro-Intestinal
Crohn’s disease
Abdominal pain
Surgical implant (mesh or other)
GI inflammation
Diverticulitis/Diverticulosis:
Other

Other:
Urinary
Kidney failure
Dialysis?

Under treatment?
Kidney disease?

What?

When?

Under treatment?
Kidney stones
Urinary tract infection
Dialysis
Other

Other:
Female Reproductive
Currently pregnant
Currently menstruating
Fibrocystic breast disease
IUD
Other

If any of the above is checked, please explain:

Other:
Musculoskeletal
Osteoporosis
Osteoarthritis
Hernia
Rheumatoid arthritis
Other

Other:
Skin
Cellulitis-acute
not acute
Treated?*
No
Yes

When?

Under treatment?
Rash
Major scars
Lumps
Other

If any of the above is checked, please explain:

Other:
Hematologic/ Lymphatic
Cuts that do not stop bleeding
Enlarged lymph nodes (glands)
Lymph nodes removed
Frequent bruising
HIV/AIDS:
Other

Other:
Neurological
Strokes
Seizures
Other

Other:
Allergies
Ear fullness
Sinus congestion
Recent sinus surgery
Other

Other:
Emotional
Stress
Anxiety
Difficulty sleeping
Depression
Other

Other:

Please list all surgeries (including Cesarean section). 


Surgery

Date

City

Please list all medications (including vitamins, hormones, and herbs) and reason for prescription. 


Medication

Reason

Is there is anything else that we should know about you or your needs before the session?
Parent or Guardian's Email Address

Email
Check to receive information, news, and discounts by e-mail.
A signed copy of this waiver will be sent to the email address you provide.
Client's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Primary Care Physician and Clinic:
For what reason are you seeking Manual Lymphatic Drainage?
Medical reason
Relaxation

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

Please describe your problem including where it is and its severity.

Please mark all current and previous conditions that apply

General
Fever

Since when?

Under treatment?
Cancer
Present
past

Where?

Last treatment date:
Undergoing cancer treatment

Last chemotherapy session

Last radio session

Additional info may be needed 

Arteriosclerosis
Carotid sinus issues
Hyperthyroidism
Liver Cirrhosis
Other

Other:
Ears, Nose, Throat
Ringing in ears
Sinus problems
Earaches
Other

Other:
Cardiovascular
Congestive heart failure
Treated?*
No
Yes

When?

Under treatment?
Acute deep vein thrombosis
Treated?*
No
Yes

When?

Under treatment?
Blood clots?
Treated? *
No
Yes

When?

Under treatment?
Chest pain or pressure
Swelling of legs
Palpitations
Varicose veins
Dizziness
Heart attack
High/Low blood pressure
Aneurysm
Cardiac arrhythmia
Other

Other:
Gastro-Intestinal
Crohn’s disease
Abdominal pain
Surgical implant (mesh or other)
GI inflammation
Diverticulitis/Diverticulosis:
Other

Other:
Urinary
Kidney failure
Dialysis?

Under treatment?
Kidney disease?

What?

When?

Under treatment?
Kidney stones
Urinary tract infection
Dialysis
Other

Other:
Female Reproductive
Currently pregnant
Currently menstruating
Fibrocystic breast disease
IUD
Other

If any of the above is checked, please explain:

Other:
Musculoskeletal
Osteoporosis
Osteoarthritis
Hernia
Rheumatoid arthritis
Other

Other:
Skin
Cellulitis-acute
not acute
Treated?*
No
Yes

When?

Under treatment?
Rash
Major scars
Lumps
Other

If any of the above is checked, please explain:

Other:
Hematologic/ Lymphatic
Cuts that do not stop bleeding
Enlarged lymph nodes (glands)
Lymph nodes removed
Frequent bruising
HIV/AIDS:
Other

Other:
Neurological
Strokes
Seizures
Other

Other:
Allergies
Ear fullness
Sinus congestion
Recent sinus surgery
Other

Other:
Emotional
Stress
Anxiety
Difficulty sleeping
Depression
Other

Other:

Please list all surgeries (including Cesarean section). 


Surgery

Date

City

Please list all medications (including vitamins, hormones, and herbs) and reason for prescription. 


Medication

Reason

Is there is anything else that we should know about you or your needs before the session?
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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