Manual Lymphatic Drainage Massage Intake Form

 

 

Name___________________________________________________________  Date_____________________

 

 

Address___________________________________________________________________________________

                 Street                                                            City                                  Province              Postal Code

 

Date of Birth______________ Home Number ___________________ Cell Number______________________

 

 

Emergency Contact _________________________________________________________________________

                                  Name                                                          Relationship                         Number

 

Are you presently taking any medication?  __________Yes    ____________No

 

Please Explain:

 

 

 

 

 

Have you had a recent major surgical procedure or plan to have a surgical procedure done? ____ Yes    ____ No

 

Please Explain:

 

 

 

 

Are you currently seeing a Chiropractor, Physical Therapist, or Physician for an ongoing issue?

 

____ Yes    ____No

 

Please Explain:

 

 

 

 

Please circle your stress level:

 

Low   1   2   3   4   5   High

 

 

Are you allergic to any Lotions or Oils?  ____ Yes    ____ No

 

Please Explain: ______________________________________________________

 

 

 

Intake Form

 

Circle the following conditions that apply to you, past and present.  Please add your comments to clarify the condition.

 

Musculo-Skeletal                                         Digestive                                Skin

 

Headaches                                                  Indigestion                               Rashes                         

Joint stiffness/swelling                                Constipation                            Allergies

Spasms/cramps                                           Intestinal gas/bloating              AthleteÕs foot

Broken/Fractured bones                              Diarrhea                                   Acne or Rosacea

Strains/Sprains                                            Irritable bowel syndrome          Impetigo

Back, hip pain                                            CrohnÕs Disease                       Hemophelia

Shoulder, neck, arm, hand pain                   Colitis

Leg, foot pain                                            Other: _____________           Other

Chest, ribs, abdominal pain                        

Problems walking                                                                                       Loss of Appetite

Jaw pain/TMJ                                             Nervous System                    Depression

Tendonitis                                                                                                 Difficulty concentrating

Bursitis                                                       Numbness/tingling                    Hearing Impaired

Arthritis                                                     Fatigue                                     Visually Impaired

Osteoporosis                                              Sleep disorders                          Diabetes

Scoliosis                                                     Ulcers                                      Fibromyalgia

Other:________________                        Paralysis                                  Lymph Node Removal___________

                                                                        Herpes/shingles                        Cancer

Circulator/Respiratory                          Cerebral Palsy                          Tuberculosis

                                                                        Epilepsy                                   Acute Inflammation

Dizziness                                                    Chronic Fatigue Syndrome       Acute Infection

Shortness of breath                                    Multiple Sclerosis                     Radiation

Fainting                                                     Muscular Dystrophy                 Other: _______________________

Cold feet or hands                                      ParkinsonÕs Disease

Cold sweats                                                Other: __________________

Stroke

Heart condition

Congestive Heart Failure

Blood Clots                                                                                                Reproductive System

Thrombosis

Varicose Veins                                                                                            Pregnancy

High Blood Pressure/Low Blood Pressure   

Lymphedema                                                                                            

Allergies:­­_________________________________________________

Asthma                                                                                                     

High blood pressure

Low blood pressure                                    

Other _________________

 

     I understand that manual lymphatic drainage is for the purpose of accelerating healing; i.e., reduction of

bruising and swelling, pain relief and relaxation. 

     I understand that the spa therapist does not diagnose illness, disease or any other physical or mental disorder.  As such, the spa therapist does not prescribe medical treatment or pharmaceuticals.

     I have stated all the conditions that I am aware of, and this information is true and accurate.  I understand that the information provided is for safety purposes only and will be kept strictly confidential.

           I hereby give my consent to receive manual lymphatic drainage massage and all future sessions of MLD              will be understood to be validation of this written consent.

ClientÕs signature_________________________________________ Date__________________________

Treatment Record

 

Date

Client Remarks

Therapist Remarks

Session Length

Notes