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MLD Assessment Form

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Name *

First

Last

Email *

Birthday

Phone

Gender

Male
Female

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Do you have any of the following conditions:

Heart Condition *

Yes
No

Active Cancer *

Yes
No

Active Infection *

Yes
No

Recent Surgery *

Yes
No

Diabetes *

Yes
No

High Blood Pressure *

Yes
No

Cellulitus/Dermatitis *

Yes
No

DVT *

Yes
No

Kidney concerns *

Yes
No

Arthritis/Osteoporosis *

Yes
No

Edema *

Yes
No

Bronchial Asthma *

Yes
No

Thyroid dysfunction *

Yes
No

Back/Spinal issues *

Yes
No

Fibromyalgia *

Yes
No

IBS/Colitis *

Yes
No

Ehlers Danlos Syndrome *

Yes
No

Any allergies *

Yes
No

Sensitive Skin *

Yes
No

If you have answered 'YES' to any of the above questions, please explain further:

Do you require written permission from your GP/Surgeon to have MLD? *

Yes
No

Post-Op:

What surgical procedure(s) did you have?

Date of Surgery:

How long did the surgery last

When were you discharged from hospital?

Did you experience any post-op complications?

What advice/information have you been given about changing your dressings?

Are you in physical pain right now? Please describe

May the therapist contact your GP / Consultants if appropriate? *

Yes
No

Therapist may require a clearance letter from Doctor prior to commencing treatment.

Are you currently taking any medication?

Have you had Lymphatic drainage before? *

Yes
No

What is your reason for having Lymphatic drainage and what are your expectations from the treatment?

Do you exercise, if yes, how often?

Do you have good posture?

Do you have any mobility issues?

PATIENT CONSENT

I have been informed of the physical nature of the assessment required and possible treatment strategies and give my consent:

I give my consent to photographs being taken: (For clinic purposes) *

Yes
No

Name *

First

Last

Date *

Message

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About
Treatments
Lipoedema
Lymphoedema
Nutrition
Vouchers