Manual Lymphatic Drainage Intake Form printable pdf download

From Scratch Wellness Services

Jennifer Stanley

630-945-3867

MANUAL LYMPHATIC DRAINAGE INTAKE FORM

Name_________________________________________________ Todayʼs Date________________

Address______________________________________________________City______________________

State_____Zip______________ Home Phone________________________Work Phone______________

Email Address_______________________________________Birthdate_________________Age______

May we contact you by email to let you know of upcoming workshops and classes? Yes_____ No_______

Whom may we thank for referring you? ________________________________________________

Height_____________Weight_____________Blood Pressure_________________

What is the reason for your visit?_____________________________________________________

__________________________________________________________________________________________

Do you have any primary health or emotional concerns?________________________________

__________________________________________________________________________________________

Are you currently taking any prescription drugs? Which ones?____________________________________

__________________________________________________________________________________________

Are you currently taking any vitamins or herbal supplements? Which ones?_________________________

__________________________________________________________________________________________

Do you have any allergies?______________________________________________Stress?____________

Do you bruise easily?______________Car accidents?________________________________________

Have you suffered major trauma in your life?__________________________________________________

Do you sleep well at night?_______________________________________________________________

Do you suffer from constipation or digestive issues? Which ones?_________________________________

__________________________________________________________________________________________

Are you sensitive to any smells or essential oils? Which ones?_____________________________________

I understand that all information shared in this visit is conﬁdential and for educational purposes only and that

it is not intended to replace your general medical practitioner. I understand that all bodywork performed is

intended to promote health.

Signed___________________________________________________Date________________________

Manual Lymphatic Drainage Intake Form