MANUAL LYPHATIC DRAINAGE INTAKE FORM

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MANUAL LYMPHATIC MASSAGE INTAKE FORM

Please fill out the following form prior to your first appointment.

First Name

Last Name

Email

Phone

Date of Birth

Emergency Contact

Emergency Contact's Phone

Are you suffering from a medical condition, illness, or injury?

No

Yes

If so, what?

Have you had surgery in the last 12 months?

No

Yes

If so, what surgery?

Name of Surgeon

Surgeon's Phone

Date of Surgery

Name of Facility

Facility Phone

PERSONAL PAST HISTORY

Arthritis / Joint Problems

No

Yes

Circulation Problems

No

Yes

High Blood Pressure

No

Yes

Rheumatic Fever

No

Yes

Asthma

No

Yes

CollegenVasular Diseae (lupus)

No

Yes

HIV / AIDS

No

Yes

Stroke

No

Yes

Aneurysm

No

Yes

Convulsions/ Epilepsy

No

Yes

Kidney Infections / Stones

No

Yes

Thyroid Disease

No

Yes

Back Problems

No

Yes

Deep Vein Thrombosis

No

Yes

Liver Disease

No

Yes

Tuberculosis

No

Yes

Bowel Problems

No

Yes

Depression, Anxiety Seizures

No

Yes

Migraine Headaches

No

Yes

Other Illnesses

Broken Bones

No

Yes

Diabetes

No

Yes

Osteoporosis

No

Yes

Other Illnesses

Cancer (Any Kind)

No

Yes

Heart Attack / Problems

No

Yes

Pneumonia

No

Yes

Other Illnesses

If you answered yes to any question, please elaborate

Initials

I declare that the info I’ve provided is accurate & complete

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