MLD Intake Form

Section 1: Personal Information

First Name

Last Name

Date of Birth

Month

Day

Year

Phone

Gender

Occupation

Primary Physician (name and practice)

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Phone

How did you hear about us?

Referred by (name, if applicable)

Section 2: Reason for Visit

What brings you in for Manual Lymphatic Drainage today? (check all that apply)

How long have you been experiencing your current symptoms?

Have you received MLD or lymphatic drainage before?

Yes

If yes, approximately when and where?

Section 3: Symptom Screening — This section helps us tailor your session and ensure it is appropriate for you today. Please answer as accurately as you can.

Do you experience swelling or heaviness in your legs, ankles, or feet?

Yes - both legs

Yes - one leg only

Does pressing the skin in a swollen area leave a dent or pit?

Yes

Not sure

Do you experience a sense of pressure, fullness, or dragging in your lower abdomen or pelvic area?

Yes

Sometimes

Do you experience any of the following? (check all that apply)

Recurring skin infections (cellulitis) in the same area

Tightness or restricted movement in a limb

Skin thickening or hardening

Varicose veins or spider veins

Aching or fatigue in the legs after standing

None of the above

Have you been told by a doctor that you have, or may have, any of the following? (check all that apply)

Section 4: Medications & Supplements

Are you currently taking any medications?

Yes

If yes, please list medication name and what it is for:

Are you currently taking a GLP-1 medication for weight management? (e.g., Ozempic, Wegovy, Zepbound, Mounjaro, Saxenda)

Yes

If yes to GLP-1, are you experiencing any of the following? (check all that apply)

Rapid or significant weight loss (more than 1-2 lbs/week)

Changes in skin texture or looseness

Unusual fatigue or muscle weakness

Nausea or digestive changes

None of the above

Are you taking any diuretics (water pills)?

Yes

Are you taking any blood thinners or anticoagulants?

Yes

Are you taking any supplements or herbal remedies? If yes, please list:

Section 5: Medical History

Are you currently pregnant?

Yes

If pregnant, how far along?

Have you had any surgeries or medical procedures in the past 12 months?

Yes

If yes, please list procedure and approximate date:

Have you had any orthopedic injuries?

Yes

If yes, please describe:

Please explain any conditions checked above:

Are there any other health conditions not listed above that you'd like us to know about?

Section 6: Referral Flags — These questions help us make sure your session is safe and appropriate, and to support continuity with your other providers where needed.

Has a doctor ever advised you to avoid massage or lymphatic work?

Yes

If yes, please explain:

Are you currently under the care of a physician, specialist, or physical therapist for a lymphatic, circulatory, or pelvic condition?

Yes

If yes, which provider and for what condition?

Have you experienced unexplained swelling lasting more than two weeks that has not been evaluated by a doctor?

Yes

Do you have any allergies or sensitivities (products, pressure, latex, etc.)?

Yes

Not sure

If yes, please explain:

Section 7: Goals

What are your goals for today's session?

Is there anything else you'd like Christina to know before your appointment?

Consent & Signature

By signing below, I confirm that the information provided is accurate and complete to the best of my knowledge. I understand that this intake is not a medical diagnosis and that Maison Papillon may use this information to tailor my session or, where appropriate, recommend follow-up with another provider.

I agree to the use of electronic records and signatures.

Section 1: Personal Information

First Name

Last Name

Date of Birth

Month

Day

Year

Primary Physician (name and practice)

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Phone

How did you hear about us?

Referred by (name, if applicable)

Section 2: Reason for Visit

What brings you in for Manual Lymphatic Drainage today? (check all that apply)

How long have you been experiencing your current symptoms?

Have you received MLD or lymphatic drainage before?

Yes

If yes, approximately when and where?

Section 3: Symptom Screening — This section helps us tailor your session and ensure it is appropriate for you today. Please answer as accurately as you can.

Do you experience swelling or heaviness in your legs, ankles, or feet?

Yes - both legs

Yes - one leg only

Does pressing the skin in a swollen area leave a dent or pit?

Yes

Not sure

Do you experience a sense of pressure, fullness, or dragging in your lower abdomen or pelvic area?

Yes

Sometimes

Do you experience any of the following? (check all that apply)

Recurring skin infections (cellulitis) in the same area

Tightness or restricted movement in a limb

Skin thickening or hardening

Varicose veins or spider veins

Aching or fatigue in the legs after standing

None of the above

Have you been told by a doctor that you have, or may have, any of the following? (check all that apply)

Section 4: Medications & Supplements

Are you currently taking any medications?

Yes

If yes, please list medication name and what it is for:

Are you currently taking a GLP-1 medication for weight management? (e.g., Ozempic, Wegovy, Zepbound, Mounjaro, Saxenda)

Yes

If yes to GLP-1, are you experiencing any of the following? (check all that apply)

Rapid or significant weight loss (more than 1-2 lbs/week)

Changes in skin texture or looseness

Unusual fatigue or muscle weakness

Nausea or digestive changes

None of the above

Are you taking any diuretics (water pills)?

Yes

Are you taking any blood thinners or anticoagulants?

Yes

Are you taking any supplements or herbal remedies? If yes, please list:

Section 5: Medical History

Are you currently pregnant?

Yes

If pregnant, how far along?

Have you had any surgeries or medical procedures in the past 12 months?

Yes

If yes, please list procedure and approximate date:

Have you had any orthopedic injuries?

Yes

If yes, please describe:

Please explain any conditions checked above:

Are there any other health conditions not listed above that you'd like us to know about?

Section 6: Referral Flags — These questions help us make sure your session is safe and appropriate, and to support continuity with your other providers where needed.

Has a doctor ever advised you to avoid massage or lymphatic work?

Yes

If yes, please explain:

Are you currently under the care of a physician, specialist, or physical therapist for a lymphatic, circulatory, or pelvic condition?

Yes

If yes, which provider and for what condition?

Have you experienced unexplained swelling lasting more than two weeks that has not been evaluated by a doctor?

Yes

Do you have any allergies or sensitivities (products, pressure, latex, etc.)?

Yes

Not sure

If yes, please explain:

Section 7: Goals

What are your goals for today's session?

Is there anything else you'd like Christina to know before your appointment?

Consent & Signature

I agree to the use of electronic records and signatures.