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Madison Lymphatics & Bodywork

Manual Lymphatic Drainage Intake Form

"*" indicates required fields

Name
Address*

For what reason are you seeking Manual Lymphatic Drainage?*

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*
Ears, Nose, Throat*
Cardiovascular*
Gastro-Intestinal*
Urinary*
Female Reproductive*
Musculoskeletal*
Skin*
Hematologic/ Lymphatic*
Neurological*
Allergies*
Emotional*

Please list all surgeries (including Cesarean section).

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Surgery
Date
Hospital and Surgeon
 

Please list all medications (including vitamins, hormones, and herbs) and reason for prescription.

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Medication
Reason
 

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 massage/ bodywork 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 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.
Consent to Treatment of Minor: By my signature below, I hereby authorize Carmela Wiese, LMT, to administer Manual Lymphatic Drainage techniques to my child or dependent as they deem necessary. Signature of Parent or Guardian