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Lymphatic Drainage Intake Form - Cimpress

Date post: 26-Nov-2021
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Name: __________________________________________ Today’s Date:_________ Address:________________________________________________________________ Phone:___________________________Email:__________________________________ Emergency Contact: Name_____________________ Phone:__________________ Relationship to client:________________ Referred by:___________________________ Personal Health History: Please write down past or current symptoms for each category Abdominal pain Allergies Arthritis Aneurysm Autoimmune disorder Bowel problems Blood clots Broken bones Bruise Easily Cancer: Cardiovascular problem: Chronic Bronchitis Chronic Constipation Chronic Ear infections Congestive Heart Failure Clotting Deep vein thrombosis Depression/Anxiety Diabetes Enlarged lymph nodes Fatigue fever Fibrocystic Breast Gastrointestinal Issues Heart Attack Head Injury/Concussion Hematologic/Lymphatic issues High blood pressure HIV/AIDS Infection Kidney infections/stones Liver Disease Low Blood pressure Lung Disease Migraine Headaches Major organ failure Major scars Musculoskeletal Nausea Neurologic Issues Neuropathy Pneumonia Pregnancy Sinus congestion or problems Skin issues Stroke Surgery Swelling Tinnitus Thyroid Disorder/disease Transient Ischemic Attack Weight gain Other: Are you a new patient? Yes No Lymphatic Drainage Intake Form
Relationship to client:________________ Referred by:___________________________
Personal Health History: Please write down past or current symptoms for each category Abdominal pain
Lymphatic Drainage Intake Form
Are you currently undergoing cancer treatments? __________________
If yes, do you have written permission from your treatment team, to receive Manual Lymphatic Drainage,
at this time?____________________________________________________________________________
For Prenatal Clients:
Are you still experiencing morning sickness?___________________________________
Have you been told you are a high risk pregnancy?____________ If Yes, Do you have written permission
from your Obstetrician to receive Manual lymph drainage at this time?____________
For Medical Referral Clients:
Manual lymphatic drainage should not be performed under certain medical conditions, I
affirm that I have stated all my known medical conditions and answered all questions
honestly and to the best of my knowledge. 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
practitioners part should I fail to do so.
Client Signature____________________________________Date:__________________
Practitioner Signature:_______________________________Date:__________________
Consent to treatment of Minor :
By my signature below, I hereby authorize the certified manual lymphatic drainage therapist, to administer
manual lymphatic drainage to my child or dependent as they deem necessary.
Signature of Parent/Guardian:__________________________ Date:________________
What is the reason you are seeking lymphatic drainage today? ____________________________
*Please note: Manual Lymphatic Drainage (MLD) aka Lymphatic Massage, is a very powerful modality, and certain medical conditions are contraindicated and determine if and when you can receive a session. After 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, or consultation between your referring provider and myself, before proceeding. Please understand this is for your safety and well-being.
I understand that manual lymphatic drainage should not be considered a substitute for medical examination, diagnosis, or treatment, and I should see a physician, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that I will not be diagnosed, prescribed, or treated for any physical or mental illness, and that nothing said in the course of the sessions should be construed as such.
Please provide any other information, medical or otherwise, not specified in this intake form that you feel is important for the practitioner to know:_________________________
Do you give the practitioner permission to consult with your referring provider your protected health information for the purpose of this visit? No____Yes- (Please sign HIPAA Form.)
We are required by law to: * Make sure that health information that identifies you is kept private * Give you this Notice of our legal duties and privacy practices with respect to health information about you * Follow the terms of the Notice that is currently in effect
How we may use and disclose health information about you:
Changes to this Notice: We reserve the right to change this Notice. We will post a copy of the current notice in our facility with the current effective date.
(Effective August 1, 2019)
For complete, detailed information regarding privacy laws, visit www.hhs.gov/hipaa
We understand that health information about you is very personal and we are mandated by the Health Insurance Portability and Accountability Act (HIPAA) to protecting your health information. We create a record of the care and services you receive from us, and this record helps to provide you with quality care and to comply with certain legal requirements. This Notice applies to all of the records of your care generated by us, and informs you about the ways in which we may use and disclose information about you. We also describe your rights to the health information we keep about you, and describe certain obligations we have regarding the use and disclosure of your health information.
Your Medical Records: The original copy of your HIPAA form is our property. You may request a copy of your records to be transferred by completing a medical records release form. As allowed by New Mexico state law, there will be a fee for providing you with this service. We require 14 business days from the date of your request to prepare and send your records unless the records are for urgent of life threatening health issues.
Complaints: If you believe that your privacy rights have been violated, you may file a complaint with us. All complaints must be in writing. Please contact us to file a complaint. For complete, detailed information regarding privacy laws, visit www.hhs.gov/hipaa
* For Treatment * Public Health risks * For Payment * Health oversight activities * For Healthcare operations * Lawsuits and disputes * For appointment reminders * Law enforcement * As required by law * To avert a serious threat to health and safety * Coroners, health examiners and funeral directors * National Security and Intelligence activities * Protective Services for the President and others * Security Officials for Inmates
Date _____________________________________
We request that you sign this form acknowledging you have received, read, and reviewed the HIPAA Notice of Privacy Practices. If the patient is a minor, the legal guardian is automatically appointed by law to provide/receive protected information on behalf of the patient. I will notify Dr. Bornaei and/or her staff of any changes or updates to this record. This acknowledgement will become part of your records.
Acknowledgement of Receipt of HIPAA NOTICE OF PRIVACY PRACTICES: