Post-Surgery Lymphatic Drainage Health Intake Form Please complete the form below if this is your first Post-Surgery Lymphatic Drainage massage with us. Personal Information Name * First Name Last Name DOB * MM DD YYYY Phone * (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Occupation How did you find me? * Emergency Contact (Name, Relationship, Phone) Health Background & Information Sex Female Male Transgender Other Are you currently taking any medications? * Yes No If yes, please list name and use: Do you have computer implants such as a pacemaker, insulin pump or spinal stimulator? * Yes No Do you have any allergies or sensitivities? * Yes No If yes, please explain: Are you currently pregnant? * Yes No Planning to be If yes, how far along? Do you suffer from chronic pain? Yes No If yes, please explain: Please indicate any of the following that apply to you: Headaches / Migraines Stress Anxiety Arthritis Diabetes Cancer Joint Replacement High/Low Blood Pressure Neuropathy Fibromyalgia Digestion Issues Stroke Seizure Heart Attack Numbness Kidney Dysfunction Blood Clots Depression Joint Pain Sinusitis Dizziness Fatigue Abdominal Pain Bloating Hernia / Rupture Varicose / Spider Veins Osteoporosis Skin Condition Autoimmune Disorder Other (please explain below) Have you ever received MLD before? Yes No If so, when? What are your goals for this treatment session? * How would you describe your general health? * It isn't the best. I struggle often. It is okay, but not as good as it could be. I try to maintain good health. I consider myself healthy. How would you describe your lifestyle? Consider: Dietary Habits, Exercise Habits, Rest, Stress Levels, Emotional well being, Work-Life Balance, Overall Happiness + Satisfaction. Do you take in high amounts of any of the following? Caffeine (4+ servings per day) Nicotine (5+ cigarettes/vape breaks) Alcohol (7+ drinks per week) Fast Food (2+ times per week) Water (8 ounces/half a gallon per day) For Clients undergoing cancer treatments What was your diagnosis? Are you currently undergoing cancer treatment? Yes No Currently in Radiation Do you have written permission from your treatment team to receive MLD at this time? Yes No What was the date of your last treatment? Do you give written permission to contact your treatment team to receive MLD at this time? Yes No Were drains used in the procedure? Yes No Are all surgical sites healed? Yes No Date of last chemotherapy session How many sessions have you had and how many were recommended? How many radiation sessions have you had and how many were recommended? Please describe the full procedure and if there were any complications For Clients who have received reconstructive or cosmetic surgery procedures Did your surgeon recommend post surgical MLD? Yes No Have you been cleared by your doctor to receive MLD? Yes No If so, have you received any MLD sessions yet? How many sessions? Are you in pain? Yes No If so, where? Are you experiencing swelling or bruising? Yes No If so, where? Please mark ALL surgeries/procedures you have undergone: Liposuction 360 Abdomen Waist/Flanks Arms Hips/Buttocks Back Thighs Inner knee Calves/Ankles Neck/Chin Neck & Face Face Lift Rhinoplasty Eyes/Brows Cheek Augmentation Neck/Chin Breast Augmentation: Implant Augmentation: Fat Trasffer Lift Removal Revision Nipple Removal Reconstruction Breast Reconstruction Expanders Areola: Removal Areola: Reconstruction Body Lifts Arm lift Body lift Body Contouring Mommy Makeover Abdominoplasty/Tummy Tuck BBL Hip Augmentation Other surgical procedures Did you have issues with blood clots or clotting? Yes No Were drains used following the procedure? Yes No I currently have drains Were you/are you in a compression garment? Yes, I was Yes, I still am No Are you noticing thickening or fibrosis (hard spots)? Yes No Please provide all the details of your recent surgery (date, hospital/clinic, surgeon) Please describe and provide details if any of the following pertains to you: Prior surgeries, Auto Accidents, Falls or Injuries, Pregnancies Is there anything else that your therapist should know before your session? COVID Protocol Do you now, or have you recently had any respiratory or flu symptoms? * Yes No Have you had a fever in the last 24 hours? * Yes No Have you been in contact with anyone in the last 14 days who has had COVID-19 symptoms? * Yes No Would you prefer your practitioner to wear a mask during your appointment? I have no preference, without is just fine. Yes, please! Disclaimers I understand that the Manual Lymphatic Drainage I receive is provided for the basic purpose of improving the flow or my lymphatic system and also for relaxation. I further acknowledge that my practitioner may integrate the use of a Medicupping machine on gentle suction during certain stages of healing, which is intended to assist lymphatic fluid movement and management of scar tissue. 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. * Please Initial. I further understand that this bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physical, chiropractor, or other qualified medical specialist for any medical 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 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 initial. I understand that, because bodywork involves maintained touch and close proximity over an extended period of time, there may be elevated risk of disease transmission, including COVID-19. * Please Initial. Please note: It is important that you complete this intake form in full. Manual Lymphatic Drainage (MLD) is a very powerful modality and certain medical conditions are contraindicated and determine if or 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. Some conditions will require a note from your doctor before proceeding. Please understand this is for your safety and well-being. The Zen Chameleon and Practitioner, Courtney, reserves the right to refuse, postpone, or terminate treatment whenever we deem it in the best interest of one or more parties. * Please initial. Release of Records/Permission to Communicate Consent: I hear-by give The Zen Chameleon and Practitioner, Courtney, to communicate with any and all practitioners involved in my treatment as they deem necessary. Please note: We will inform you of this line of communication if/when it needs to take place. * Please Initial. Cancellation Policy: I agree to pay the full fee of service upon the day of service. I understand if I miss my service and do not give 24 hours notice of cancellation, that I am still held responsible to pay the full service fee. * Please Initial. Minors: Parents must accompany any minor under 18 years of age to each and every appointment. Please Initial. By signing this form, I acknowledge that I am aware of the risks involved and give consent to receive massage and bodywork from this practitioner. I acknowledge that this facility and the therapist will not be held liable for indications that arise during or after the treatment, and I agree to notify the therapist if there is any discomfort during my session. * Please type your full name. Thank you!
