Lymphatic Drainage Massage Client History Form

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Lymphatic Drainage Massage Client History Form 1 Please fill out this form as thoroughly as possible. All information is for the purpose of providing massage therapy and will be kept in the strictest confidence. ---------------------------------------------------------------------------------------------------------------------------------------------- Name Home/Cell Phone DOB M/F Occupation Referred by Present symptoms (your major complaint) When did you first notice major complaint? Minor complaints (other areas of pain or concern) What brought it on? What activities aggravate the condition? Is this condition getting progressively worse? _ Is this condition interfering with your work? Your sleep? Daily routine? _ What do you believe is wrong with you? What have you done to get relief? Has there been a medical diagnosis? If yes, what? By whom? X-Rays? MRI?

2 Past History: Have you had similar problems before? If yes, explain: When? Did they prevent you from working? What caused the episode(s)? What relieved them? Did they hospitalize you? Disable you? What was the previous diagnosis? What were the treatments? Did they help? Name of the attending physician? Are you on any medication? List: How many physicians have treated you for this illness or injury? Are you taking any of the following? Circle all that apply: Laxatives Sedatives Aspirins Vitamins Anti-Depressants Sleeping Pills Hormones Insulin Herbs Diet Supplements Social Habits: Heavy Moderate Light None Alcohol Coffee/Tea/Caffeine Tobacco Exercise Weekly Sugar Intake Have you ever : Yes No Describe briefly: Had any operations? Broken any bones? Been in an accident? Had whiplash?

3 Other: How many bowel movements daily? Do you have a history of constipation? If yes, what have you done to relieve it? Age of your mattress? Comfortable? Uncomfortable? Do you use a foam pillow? A bedboard? Do you sleep on your side? Back? Stomach? Do you wear Heel lifts? Sole lifts? Arch supports? Inner soles? Which hand is your dominant hand? Left: Right: Which pocket do you carry a wallet in? Left: Right: Which shoulder do you carry a purse or other bag on? Left: Right: Do you have any difficulty with the following? Circle all that apply: Headaches Ringing in ears Anemia Painful joints Shooting head pains Wearing glasses Rheumatic fever Swollen joints Sinus trouble Light bothers eyes Nervous stomach Arthritis Loss of smell Irritability Stomach trouble Pinched nerves Hay fever Muscle spasms in neck Ulcers Pins & Needles in leg Asthma Grating in neck Nerves and nervousness Swollen ankles Loss of taste Tightness of shoulder muscles Inner tension Cold feet Tightness in throat Neuritis in shoulders and arms Cold sweats Pains in legs and feet Thyroid trouble Pins and needles in arms and Liver trouble Disc herniation hands Face flushed Cold hands Gall bladder trouble Disc rupture Twitching of face Chest pains Indigestion Slipped disc Loss of memory Shortness of breath Intestinal gas Bulging disc Fatigue T.B. Constipation Scoliosis Depression Heart pain Kidney trouble Sciatica Head feels heavy Heart palpitations Bladder trouble Skin pain Dizziness Heart attacks Diabetes Skin sensitivity to touch Fainting High blood pressure Cancer Rashes Loss of balance Low blood pressure Sleeping problems Bruise easily

4 Male only: History of prostate trouble Pain in shoulders Sacroiliac or low back pain Excessive perspiration Urination difficulty or Persistent abdominal pain Tire easily Dizziness dribbling Frequent night urination Pain on outside of legs and Lack of energy Diminished sex drive heels Burning upon urination Pain in groin area Nervousness Burning or pain during orgasm Female only: Very easily fatigued Menstruation scanty or Melancholia of long standing Breast implants missing Premenstrual Tension or Vaginal discharge IUD / Diaphragm Hysterectomy depression Painful menstruation cramps Painful breasts Birth control pills Births Menstruation excessive or prolonged Menopausal hot flashes, etc. How many pregnancies? Difficult births or pregnancies Have you had lymphatic drainage massage before? When? Where? In some cases, breast massage is a part of the lymphatic drainage work, since there are so many lymph vessels in the breasts, and the client has a choice whether to do it on her own or have the practitioner perform it. I hereby do / do not (circle one) give permission for breast massage as a part of my lymphatic drainage massage. Signature Date I acknowledge that I have received and read a copy of pages 5 and 6 of this form, Possible Reactions to Lymph Drainage Massage, and Client Instruction Sheet. I also state that all of the information I have provided on this form has been accurate and thorough to my knowledge. Signature Date

5 POSSIBLE REACTIONS TO LYMPH DRAINAGE MASSAGE You may experience detoxification reactions two to six days following a session, depending on the amount of toxins in your body. Here are some examples of possible reactions. Common Reactions: Sluggishness, nausea, muscle aches, pain, tiredness. If these don t last, they usually indicate the release of toxins. Urinary reactions: urination may be more often and/or in greater quantity. The urine may be very concentrated at the beginning and very clear after a while (less toxins, more water). There may be a strong odor (toxins). Regarding sleep: You may feel a pleasant tiredness and sleep more. Afterward you may feel very fresh and alert. However, you may have the opposite reaction and not want to sleep. You may feel so energized that you will not want to sleep, but you will also not be tired in the morning. Some bones can spontaneously readjust (tension release). You may experience: o Better memory o Better taste also better taste for life o Better smell o Better visual perception of distance and color Emotions: You may cry, sigh, or yawn a lot during the session (signs of emotional release). Acute signs of fever can be signs of detoxification reactions and should not remain more than two or three days. The Nothing Reaction: In about 6% of cases the nothing reaction may indicate another problem that must be addressed first, e.g., bone misalignment, lack of vitamins or nutrients, teeth problems (fillings, infections), etc. CLIENT INSTRUCTION SHEET - LYMPH DRAINAGE MASSAGE Lymph Drainage Therapy is a method of stimulating your lymph and body fluid. It is a very gentle hands-on procedure that will help you eliminate fluid retention, cleanse your body and eliminate toxins and trapped proteins in your tissues. It will stimulate your immune system, help you to relax, and release stress and emotional trauma. It has many other effects on your body, as well. To receive the best results, you should respect the following preliminary procedures. Before the Session You are encouraged to tell your therapist if you have any medical conditions, including thyroid problems, a high fever or infection, acute heart or kidney conditions, a fresh scar or burn, or if you are menstruating or pregnant. You should also mention if you are wearing contact lenses. For optimal results, and to prepare the system for the cleansing, please drink a lot of water or fresh, natural juice for the two to four days preceding a session. At a minimum, eat lightly the day of your initial drainage in order to avoid possible toxic reactions. Raw fruits and raw or steamed vegetables are preferred. During the Session It is not necessary for you to disrobe. Share with your therapist if your back or neck is uncomfortable or if you feel cold. Prepare yourself to relax and be completely cared for this is a special time for you. The

therapist will need to concentrate in order to achieve the best results; therefore, silence is appreciated during the slow, rhythmic movements of the lymph drainage. During the session, your practitioner may ask you to breathe deeply and slowly at various times in order to activate the lymphatic system. After the Session You will be encouraged to give any feedback or share any feelings or emotions you may have felt during the session. You may or may not have post-treatment reactions. You may want to sleep a lot or you may experience sluggishness or muscle aches. This simply means that toxins are being eliminated from your body. Be sure that you are steady before driving. It is very important for you to drink as much as possible to help flush out the toxins. 6

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