Reviews 1 — Cecilia Ryan Wellness

Manual Lymphatic Drainage Intake Form

Thank you for taking the time to fill out and sign the consultation form below. Your data and personal information are safe with me. I do not share or sell any data I receive and adhere strictly to patient-therapist confidentiality. Please be advised that the treatment offered should never be regarded as an alternative to conventional medical treatment. However, Manual Lymphatic Drainage can complement other treatments. If you are currently receiving medical treatment, please consult with your physician prior to your appointment! Please be advised that Manual Lymphatic Drainage is not indicated for all clients! The most common contraindications for MLD are - but are not limited to - Acute Infections, Congestive Heart Failure (CHF), Acute Deep Venous Thrombosis (DVT), Fever, Malignant Disease (requires a physician's approval), Renal Dysfunction (requires a physician’s approval), Cold/Flu symptoms.

Name

First Name

Last Name

Date of Birth

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Name

First and Last

Emergency Contact Phone Number

Phone Number

Occupation

Reason for MLD Treatment

Are you receiving any other therapies?

Medical History

Do you suffer from medical conditions of:

Any details necessary to the above conditions?

Any current medications? Please list here.

Allergies

Do you suffer from allergies related to:

Any details of your allergies such as triggers / coping mechanisms / medications etc.?

System Assessment

Musculo-Skeletal System Concerns

Any other details regarding your musculo-skeletal system?

Urinary System Concerns

Any other details regarding your urinary health?

Digestive Concerns

Appetite

Meals

Digestion

Skin Concerns

Any other details regarding your skin health?

Lymphatic System

Any other details regarding your lymphatic health?

Circulatory System

Any other details regarding your circulatory health?

Reproductive System - Male

Any other details regarding your reproductive health?

Reproductive System - Female

Pregnant?

Menstrual Cycle

Additional Reproductive System Concerns

Any other details regarding your reproductive health?

Nervous System Concerns

Any other details regarding your nervous system health?

Please rate your current stress level on a scale of 1-10.

1 = very low level, 10 = very high-level stress

Please provide any details, if needed, regarding common sources of stress in your life:

Energy Level

Please provide any details, if needed, regarding your energy level:

Lifestyle - please list any regular exercises and activities you engage in:

Manual Lymphatic Drainage can - but does not have to - include treatment of the breast tissue:

Yes, I agree to have treatment done to my breast tissue

No, I do not want treatment done to my breast tissue

Signature and Consent

I agree to receive Manual Lymphatic Drainage. I am aware of the benefits and risks of Manual Lymphatic Drainage and give my consent for this treatment. I acknowledge that Manual Lymphatic Drainage is not a substitute for medical care, medical examination, or diagnosis. I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status. Disclaimer: The results and effects of manual lymphatic drainage vary from person to person. There is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments.