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Manual Lymphatic Drainage Intake Form

Name

Date

Date of Birth

Street Address

Address Line 2

City

State/Province/Region

Postal Zip Code

Country/Region

Email

(Email addresses will not be used for any other purpose or be distributed or sold to any third party.)

Phone

In Case of Emergency

Emergency Contact Number

Name of Primary Care Physican

Referred by:

For what reason are you seeking Manual Lymphatic Drainage?
TherapeuticMedical Issue

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

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

Current Medications: Blood Thinners/Pain Medications

Personal Past History of Illness
AneurysmArthritis/ Joint Back ProblemsAsthmaBowel ProblemsBroken BonesCancer (any type)Circulation ProblemsDeep Vein ThrombosisDiabetesHeart Attack/Problems (past 6 months)High Blood PressureImplantsKidney DiseaseLiver DiseaseLupusMigraine HeadachesOsteoporosisPain PatchesPneumonia/Lung DiseaseStroke (past 6 months)Thyroid Disease

Other

If yes to any of the above, please describe:

Review of Current Symptoms: General Check all that apply
FeverRecent SurgeryUndergoing Cancer Treatments

Date of last chemotherapy treatment (if applicable)

Review of Current Symptoms: Ears, Nose, Throat Check all that apply
EarachesRinging in earsSinus Problems

Review of Current Symptoms: Cardiovascular Check all that apply
Acute Deep Vein ThrombosisChest Pain or PressureCongestive Heart FailureDizzinessPalpitationsSwelling of Legs

Other Cardiovascular

Review of Current Symptoms: Gastrointestinal Check all that apply
Abdominal PainCystsNauseaTumors

Review of Current Symptoms: Urinary Check all that apply
Kidney StonesUrinary Tract Infection

Review of Current Symptoms: Other Check all that apply
ArthritisDizzinessEnlarged lymph nodes (glands)Epilepsy/SeizuresFibrocystic Breast DiseaseLymph Nodes RemovedMolesOpen WoundsOsteoporosisPregnantRash

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

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 Manual Lymph Massage 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 sessions. 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. Your health is important to me.

Thank you.

Tracy Stevenson, LMT, MLDT-VT, NCTMB

Client Electronic Signature

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