Cloud9 Massage Client Intake Form

Cloud 9 Massage Manual Lymphatic Drainage Intake Form

In this form are the details of your massage session with MASSAGE CLOUD9. Please take a moment to carefully answer the following questions. If you have a specific medical condition or specific symptoms, massage/bodywork may be contraindicated. A referral from your primary care provider may be required prior to service being provided. Manual Lymphatic Drainage (MLD) is a gentle treatment to speed up the movement of lymph fluid to relieve pain andswelling, assist the body’s own healing processes, boost immunity, and reduce the chance of scar formation. The pressureused during this session is extremely light. If deeper pressure is used, the session will not be as effective with its results and could exacerbate the condition. Thank you for understanding.
Submit Date
Client Full Name

First NameLast Name
Phone (to receive appointment reminder)*

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email address (to receive appointment reminder)*
Occupation
How do you know about us?
Referred by
Emergency Contact*

NamePhone Number
Have you received a MLD before?

YesNo
For Clients with History of Cancer ONLY

(If not applicable to you, please skip to next section)
What was your diagnosis?
Are you currently undergoing cancer treatment?

YesNo
Radiation?

YesNo
Do you have written permission from your treatment team to receive MLD at this time?

YesNo
What was the date of your last treatment?
Were drains used in the procedure?*

YesNo
How many?
Are surgical sites healed?

YesNo
Date of last chemotherapy session?
Date of last chemotherapy session?   Date
How many sessions have you had?Sessions
How many are recommended?Sessions
How many radiation sessions have you had? SessionsHow many are recommended? Sessions
Please describe the full procedure and if there were any complications   Describe
For Clients Who Have Received Surgical Procedures
Date of your surgery
Did your surgeon recommend post surgical MLD?
Yes   No
Have you been cleared by your doctor to receive MLD?
Yes   No
If so, have you received MLD after surgery?
Yes   No
How many sessions?   Sessions
Are you in pain?   Yes   No
If so, where?   Locations
Are you experiencing swelling or bruising?   Yes   No
If so, where?   Locations
Please mark ALL surgeries/procedures, or list if not seen below:
LIPOSUCTION
360 (around entire waist, abdomen, back) Abdomen Arms Back Buttocks Chin Hips Knees Neck Thighs Waist and flanks
BREAST
Areola
Augmentation
   Fat transfer
   Implants   Saline   Silicone
Breast Lift   Expanders   Implant Removal   Implant Revision   Reduction
BODY LIFTS
Abdominoplasty (Tummy Tuck)
Arm Lift
Body Contouring (Skin Removal   Buttock Enhancement (Brazilian Butt Lift - BBL)   Mommy Makeover (please ensure you check all procedures included)   Thigh Lift
FACE/NECK
Brow Lift Cheek Augmentation Chin Ear Eyelid Face Lift Facial Implants Neck Lift Rhinoplasty Thread Lift
GENDER AFFIRMATION SURGERY
Facial   Transfeminine    Transmasculine
Top    Transfeminine   Transmasculine
Bottom  Transfeminine   Transmasculine
Do you have issues with blood clots or clotting?
Yes   No
Were drains used following the procedure?
Yes   No    If yes, where? Location
Do you still have drains in place?
Yes   No  How many? Explain
Are you wearing compression garments?   Yes   No
Other surgery (not listed above)
Please provide details of your recent surgery - hospital/clinic, city and state, surgeon’s name, any complications during the surgery or recovery process:
Please mark all areas that apply to your surgery:
PLEASE MARK ALL CURRENT AND PREVIOUS CONDITIONS THAT APPLY TO YOU
FeverArteriosclerosisCarotid Sinus IssuesHyperthyroidismLiver CirrhosisRinging in EarsSinus ProblemsEarachesCurrently PregnantCurrently MenstruatingFibrocystic Breast DiseaseIUDStrokesSeizuresOsteoporosisOsteoarthritisHerniaRheumatoid ArthritisChest pain or pressureSwelling of legsPalpitationsVaricose VeinsDizzinessAcute Deep Vein ThrombosisCongestive Heart FailureHeart AttackHigh/Low Blood PressureAneurysmCardiac ArrhythmiaCrohn’s DiseaseAbdominal PainSurgical Implant (mesh or other)GI InflammationDiverticulitis/DiverticulosisKidney FailureKidney StonesUrinary Tract InfectionDialysisCellulitisRashMajor ScarsLumpsCuts that do not stop bleedingEnlarged Lymph Nodes/GlandsLymph Nodes RemovedFrequent BruisingHIV/AIDSOtherEar FullnessSinus CongestionRecent Sinus SurgeryStressAnxietyDifficulty SleepingDepression
Patient Consent for Treatment

Please read and sign below.

I understand that the Manual Lymphatic Drainage I receive is provided for the basic purpose of improving the flow of my lymphatic system and also for relaxation. If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort.

I further understand that massage or bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or
physical ailment of which I am aware. I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage/ bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so.

Please Note: It is important that you complete this intake in full. Manual Lymphatic Drainage (MLD) is a very powerful modality and certain medical conditions are contraindicated and determine if or when, you can receive a session. After the consultation and review of the information you have provided on this form, it will be determined if MLD should be administered to you today. Some conditions will require a note from your doctor before proceeding. Please understand this is for your safety and well-being.
Client Signature

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Cloud 9 Massage Manual Lymphatic Drainage Intake Form

For Clients with History of Cancer ONLY

For Clients Who Have Received Surgical Procedures

Please mark ALL surgeries/procedures, or list if not seen below:

Please mark all areas that apply to your surgery: