Post-Op Recovery Intake Form

Personal Information

First Name

Last Name

Date of Birth

Phone

Gender

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Phone

Surgical Information

Type of surgery / procedure

Date of surgery

Surgeon name

Hospital or surgical facility name

Were you cleared by your surgeon or medical provider for lymphatic drainage massage?

Yes

Not yet — waiting on clearance

If cleared, please describe any restrictions or notes from your provider

How many days post-op are you today?

Drains & Wound Status

Do you currently have surgical drains in place?

Yes

If yes, how many drains and where are they located?

Are any incisions still open, draining, or showing signs of infection?

Yes

Not sure

Are you wearing a compression garment?

Yes

Sometimes

Do you currently have any open incisions, areas of wound separation, actively draining areas, or fluid being expressed through a surgical opening?

Yes

If yes, please describe what you are experiencing.

Maison Papillon provides postoperative lymphatic manual therapy to support healing and reduce swelling. We do not perform wound care, incision drainage, or manually express fluid through open wounds or surgical incisions. If you are currently experiencing any of the above, we ask that you receive clearance from your surgical team before your session.

Postoperative lymphatic drainage is a phase-specific manual therapy approach designed to gently encourage lymphatic flow and support tissue recovery. It is distinct from squeezing or expressing fluid through an incision, which is not the same as lymphatic drainage and is not a service we provide. If you have questions about whether lymphatic drainage is appropriate for your current stage of recovery, we encourage you to speak with your surgeon.

Previous Postoperative Treatment

Since your surgery, has anyone performed wound care involving squeezing, pushing, or expressing fluid through an incision or surgical opening?

Yes

I'm not sure

If yes, please briefly describe:

Since your surgery, have you received manual lymphatic drainage or postoperative lymphatic massage?

Yes

I'm not sure

If approximately how many sessions have you received?

These are different types of care. Wound care involving expression of fluid through a surgical opening is not the same as manual lymphatic drainage. This information helps your therapist understand what treatment you have previously received and plan your session appropriately.

Current Symptoms

Are you experiencing any of the following? (check all that apply)

Rate your current pain or discomfort level

0 — None

1–3 Mild

4–6 Moderate

7–10 Severe

Do you experience swelling or heaviness in your legs, ankles, or feet unrelated to the surgery?

Yes

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

Yes

Not sure

Medications & Supplements

Are you currently taking any medications?

Yes

If yes, list medication name and purpose

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

Yes

If yes, 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 blood thinners or anticoagulants?

Yes

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

Medical History

Any other health conditions Christina should know about?

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

Yes

Not sure

If yes, please describe your allergies or sensitivities

Goals & Notes

What are your goals for your post-op recovery sessions?

Anything else you would like Christina to know before your appointment?

Consent & Signature

By signing below, I confirm that the information provided is accurate to the best of my knowledge. I understand that Manual Lymphatic Drainage is not a substitute for medical care and that Maison Papillon may use this information to tailor my session or recommend follow-up with my surgical provider.

I agree to the use of electronic records and signatures

Personal Information

First Name

Last Name

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Phone

Surgical Information

Type of surgery / procedure

Date of surgery

Surgeon name

Hospital or surgical facility name

Were you cleared by your surgeon or medical provider for lymphatic drainage massage?

Yes

Not yet — waiting on clearance

If cleared, please describe any restrictions or notes from your provider

How many days post-op are you today?

Drains & Wound Status

Do you currently have surgical drains in place?

Yes

If yes, how many drains and where are they located?

Are any incisions still open, draining, or showing signs of infection?

Yes

Not sure

Are you wearing a compression garment?

Yes

Sometimes

Do you currently have any open incisions, areas of wound separation, actively draining areas, or fluid being expressed through a surgical opening?

Yes

If yes, please describe what you are experiencing.

Previous Postoperative Treatment

Since your surgery, has anyone performed wound care involving squeezing, pushing, or expressing fluid through an incision or surgical opening?

Yes

I'm not sure

If yes, please briefly describe:

Since your surgery, have you received manual lymphatic drainage or postoperative lymphatic massage?

Yes

I'm not sure

If approximately how many sessions have you received?

Are you experiencing any of the following? (check all that apply)

Rate your current pain or discomfort level

0 — None

1–3 Mild

4–6 Moderate

7–10 Severe

Do you experience swelling or heaviness in your legs, ankles, or feet unrelated to the surgery?

Yes

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

Yes

Not sure

Medications & Supplements

Are you currently taking any medications?

Yes

If yes, list medication name and purpose

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

Yes

If yes, 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 blood thinners or anticoagulants?

Yes

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

Any other health conditions Christina should know about?

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

Yes

Not sure

If yes, please describe your allergies or sensitivities

What are your goals for your post-op recovery sessions?

Anything else you would like Christina to know before your appointment?

I agree to the use of electronic records and signatures