Intake Form for Craniosacral Therapy and Lymphatic Drainage.
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Personal Info
First Name
Last Name
Contact Info
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Email
Source of Referral
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Australia
Canada
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Virgin Islands, British
Virgin Islands, U.S.
Wallis And Futuna
Western Sahara
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For All Clients. General Intake.
What are the primary issues/problems/reasons that bring you to see me?
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What are your goals/expectations for this session?
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Please list and date all previous surgeries/injuries.
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Have you ever received Craniosacral Therapy (CST) or Manual Lymph Drainage (MLD)before? Are you currently receiving any other bodywork?
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Musculoskeletal Area(s) of Complaint.
Front of Head
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Back of Head
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Left or Right Shoulder/Arm/Hand
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Upper Back
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Low Back
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Left or Right Hip/Leg/Foot
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Pubic Bone
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Sacrum
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General Health History. Please check those that apply.
Abdominal Pain
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ADD/ADHD
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Allergies
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Aneurysm
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Anorexia
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Anxiety/Depression
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Appendicitis
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Arthritis
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Asthma
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Auto Accident
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Autoimmune Disorder
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High/Low Blood Pressure
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Broken/Fractured Bones
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Bronchitis
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Bruise Easily
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Bursitis
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Cancer
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Carpool Tunnel Syndrome
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Celiac Disease
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Chronic Fatigue
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Concussion or Other Head Injury
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Constipation
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Chron's Disease
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Covid-19
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Currently Pregnant. How many weeks?
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Diabetes
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Diverticulitis
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Dizziness
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Earaches
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Ear Tubes
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Eczema
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Edema
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Endometriosis
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Epilepsy
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Eye Strain/Pain
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Fainting
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Fibromyalgia
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Fibrosis
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Gas/Bloarting
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Headaches/Migraines
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Insomnia
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IBS
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Jaw Pain
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Joint Pain
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Kidney Stones
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Lyme disease
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Enlarged Lymph Nodes
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Removed Lymph Nodes
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Major Scars
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Mold Illness
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MS
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Nausea
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Numbness/Tingling
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Open Wounds
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Osteoporosis
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Pinched Nerve
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POTS
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Psoriasis
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Radiation
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Rash
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Rheumatoid Arthritis
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Sciatica
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Seizures
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Scoliosis
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Sinis Issues
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Sleep Disorders
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Spasms
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Strains/Sprains
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Stress. High/Medium/Low?
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Stroke
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Surgical Implants
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Swelling of the arms or legs
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Tendonitis
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Tinnitus
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Tonsilitis
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Tumors/Growth
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TMJ
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Trauma
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Ulcers
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UTI
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Varicose Veins
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Please include anything else you want me to know about any of the above or something not mentioned? (ex. car accidents, concussion cause)
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Please list your medications/supplements.
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For Clients Undergoing Cancer Treatments:
What was your diagnosis?
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Are you currently undergoing cancer treatment? YES/NO. Radiation? YES/NO
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Do you have written permission from your treatment team to receive MLD at this time? YES/ NO
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What was the date of your last treatment?
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Do you give written permission to contact your treatment team to receive MLD at this time?
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Please describe any past treatments and/or surgeries?
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Were drains used in the procedure? If so how many and where?
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Are surgical sites healed?
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Date of last chemotherapy and/or radiation session?
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Please describe your current treatment plan.
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Are you having any complications in your treatment physically or emotionally?
For Clients Who Have Received Plastic Surgery
Breast
Implants
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Implant Revision
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Removal
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Revision
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Fat Transfer
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Expanders
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Areola Removal
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Areola Reconstruction
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Body Lifts
Abdominoplasty
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Arm Lift
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BBL
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Body Contouring
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Body Lift
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Hip Augmentation
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Mommy Makeover
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Neck And Face
Check Augmentation
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Eyes/Brows
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Face Lift
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Neck/Chin
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Rhinoplasty
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Liposuction
360
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Abdomen
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Arms
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Back
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Calves
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Inner Knee
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Hips/Buttocks
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Neck/Chin
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Thighs
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Waist
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Please provide any details I may need to know of your surgery.
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Did you have drains after your procedure? When were they removed or when will they be?
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Were you given compression garments? Are you using them now?
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For Clients Who Have Received ANY Recent Surgery
Please describe the area/reason for your recent surgery.
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Did your surgeon recommend and/or clear you for post surgical MLD? Yes/No
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Are you in pain? If so, where and please explain.
Are you experiencing swelling or bruising? If so where?
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Review & Agree
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