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How Did You Hear About Us? Search engine (google, etc) Doctor/surgeon Local business Friend or colleague Social media Blog Booksy Other Please Specify
Reason for Seeking Manual Lymphatic Drainage Massage For what reason are you seeking Manual Lymphatic Drainage Massage? * Medical reason Relaxation Other If you are here for a medical issue, when did the problem start? Please describe your problem including where it is and its severity. *
Medical Conditions In order to create the most beneficial session, please mark all current and previous conditions that apply. If none apply, select other and write n/a. General * Fever Undergoing cancer treatment Last chemotherapy session Arteriosclerosis Carotid sinus issues Hyperthyroidism Liver Cirrhosis Other N/A If other, please explain Ears, Nose, Throat * Ringing in ears Sinus problems Earaches Other N/A If other, please explain Cardiovascular * Chest pain or pressure Swelling of legs Palpitations Varicose veins Dizziness Acute deep vein thrombosis Congestive heart failure Heart attack High/Low blood pressure Aneurysm Cardiac arrhythmia Other N/A If other, please explain Gastro-Intestinal * Crohn's disease Abdominal pain Surgical implant(mesh or other) GI inflammation Diverticulitis/Diverticulosis Other N/A If other, please explain Urinary * Kidney failure Kidney stones Urinary tract infection Dialysis Other N/A If other, please explain Female Reproductive* Currently pregnant Currently menstruating Fibrocystic breast disease IUD Other N/A If other, please explain Musculoskeletal * Osteoporosis Osteoarthritis Hernia Rheumatoid arthritis Other N/A If other, please explain Skin * Cellulitis (bacterial skin infection) Rash Major scars Lumps Other N/A If other, please explain Hematologic/Lymphatic * Cuts that do not stop bleeding Enlarged lymph nodes (glands) Lymph nodes removed Frequent bruising HIV/AIDS Factor V Leiden Clotting issues N/A If other, please explain Neurological * Strokes Seizures Other N/A If other, please explain Allergies * Ear fullness Sinus congestion Recent sinus surgery Other N/A If other, please explain Emotional * Stress Anxiety Difficulty sleeping Depression Other N/A If other, please explain
Surgeries Please list all surgeries (including Cesarean section). Surgery Date Hospital and Surgeon Add Surgery
Medications Please list all medications (including vitamins, hormones, and herbs) and reason for prescription. Medication Reason Add Medication
Additional Information Is there anything else that your MLD therapist should know about you or your needs before the session? Additional Information
Consent and Understanding I understand that the Manual Lymphatic Drainage Massage/scar tissue work I receive is provided for the basic purpose of improving the flow of my lymphatic system, to prevent scar tissue adhesions, increase scar tissue mobility 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, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that the practitioners at Lymphatic Specialists of Madison operate within the scope of their individual professional licenses and credentials. As such, they are not authorized to provide medical diagnoses or offer recommendations regarding imaging or medications. Any information shared during a session that falls outside a practitioner's professional scope should not be interpreted as medical advice. Because MLD/scar tissue work 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 Massage (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. I understand and agree to the above terms *
Consent to Treatment of Minor By my signature below, I hereby authorize practitioners at LSOM to administer Manual Lymphatic Drainage techniques to my child or dependent as they deem necessary. Signature of Parent or Guardian