Manual Lymphatic Drainage Intake Form

Check all that apply:

Headaches/Migrains

Neck Pain

Shoulder Pain

Numbness/Tingling

Sprains/Strains

Check all that apply:

Back Pain/Discomfort:

Upper

Middle

Lower

Sciatica

Check all that apply:

Piercings

Depression

Anxiety

Abuse- sexual-physical-verbal-emotional-financial

Check all that apply:

Broken Bones

Car Accidents

Surgries

Check all that apply:

Brest Surgery/ Reduction/enhancement

Pregnant

C-Section

Hysterectomy

Pure Spa Wellness