Patient Intake - MLD

Permanent Address

YesNo

YesNo

Note: Not all FMC offices accept auto or workman compensation patients.

Medical Conditions (Check all that apply):
DiabetesHeart DiseaseHigh Blood PressureKidney DiseaseLiver DiseaseCancerThrombosisRecent SurgerySkin ConditionsOthers

History of Lymphedema:
YesNo

Physical Activity:
SedentaryLight ActivityModerate ActivityHeavy Activity
Smoking:
YesNo

Alcohol Consumption:
YesNo /span>

Diet:
BalancedUnbalancedSpecial Diet

Have you had massage therapy before?
YesNo
Have you had Manual Lymphatic Drainage therapy before?
YesNo

Swelling:
YesNo

Pain or Discomfort:
YesNo

Other Symptoms or Concerns:

Areas to Treat:

I acknowledge that I have received a copy of Radiant Recharge LLC's HIPAA Privacy Notice.
I understand that Manual Lymphatic Drainage (MLD) is a gentle massage technique intended to help promote the drainage of lymphatic fluid. I acknowledge that the therapist is not a medical doctor and that MLD is not a substitute for medical treatment. I have informed the therapist of all my known physical conditions and medications and will keep the therapist updated on any changes.

Please sign below: