Client intake form

 

To ensure your safety and provide the most effective Manual Lymphatic Drainage or Craniosacral Therapy, please detail your health history in the message box below below,

ALL  INFORMATION SHARED WILL  BE KEPT CONFEDENTIAL, AND MY PRIVACY WILL BE RESPECTED.

CELL PHONE:

EMERGENCY CONTACT: and their phone

MEDICAL HISTORY

LIST IN ORDER Any  IMPORTANT AREAS OF PAIN OR DYSFUNCTION YOU FEEL IN YOUR BODY

HAVE YOU HAD ANY BOTOX FOR FILLERS IN THE PAST 6 WEEKS ?

 

HAVE YOU HAS ANY SURGURY THAT MIGHT AFFECT TREATMENT?

Ex:   C SECTION,          TUMMY TUCK,         BOWEL SURGERY            etc.:     

Please list any of the below conditions  THAT CURRENTLY APPLY – 

 

BODY

SPINA BIFIDA (MYELOMENINGOCELE)                    CURVED SPINE CAUSED BY A FALL  

ACUTE STROKE       

HEAD INJURY          CONCUSSION              

AUTO IMUNE DISORDERS

LOW BACK PAIN ,          MID BACK PAIN,               NECK PAIN,                  WHIPLASH

ARM PAIN    LEG PAIN    JOINT PAIN

CONSTANT JOINT STIFFNESS / ACHE  DIFFICULTY WALKING

BROKEN BONES                  SHOULDER PAIN                   MUSCLE STRAINS

TORN MUSCLES                  LIGAMENT SPRAINS        CARTILAGE TEARS           

 ARTHRITIS           DIABETES

GLAUCOMA of the eyes                       VARICOSE VEINS                LYMPHEDEMA 

 

NERVOUS SYSTEM

NUMBNESS/TINGLING

 DIZZINESS OR VERTIGO,    LOSS OF BALANCE,           HEARING PROBLEMS 

FREQUENT HEADACHES OR MIGRAINS

FAINTING            SEIZURES           LOSS OF COORDINATION

FREQUENT MUSCLE TWITCHING, TICS OR SPASMS

MOUTH,           THROAT,              NECK         TROUBLE SWALLOWING  

(CURRENT OR HISTORY)  GRINDING OF TEETH,                TMJ,            CLICKING JAW

 

RESPIRATORY SYSTEM

ASTHMA     CHRONIC/FREQUENT COUGHING PAIN ON BREATHING

REGULAR COLDS OR INFECTIONS  FREQUENT SHORTNESS OF BREATH

CARDIOVASCULAR SYSTEM AND PERIPHERAL VASCULAR SYSTEM

HIGH/LOW BLOOD PRESSURE,     HEART MURMURS,     HEART PALPITATIONS

IRREGULAR HEART BEAT   ANEMIA

 

GASTROINTESTINAL SYSTEM

FREQUENT CONSTIPATION        FREQUENT DIARRHEA             FREQUENT CRAMPS

ABDOMINAL PAIN   FREQUENT INDIGESTION OR GAS  FREQUENT HEARBURN

  HERNIA ,                     COLITIS,           CRON’S DISEASE,          ULCERS

 

REPRODUCTIVE SYSTEM

FREQUENT CRAMPING,        C‐SECTION

IRREGULAR CYCLE ,     FIBROIDS,           CYSTS,          OR       ENDOMETRIOSIS 

MENOPAUSE OR PERI‐MENOPAUSAL SYMPTOMS

ARE YOU PREGNANT?   IF YES, PLEASE ANSWER THE FOLLOWING:

# OF WEEKS PREGNANT                           

ANY PROBLEMS OR ISSUES WITH YOUR PREGNANCY?

 

 

Please let me know if you are not OK with smells/scents

 

Please indicate in the message box below if you  give your CONSENT FOR TREATMENT

TREATMENT FROM MICHELE TYNAN SMITH.  I UNDERSTAND THAT CRANIOSACRAL/ MANUAL LYMPHATIC DRAINAGE THERAPY REQUIRES PHYSICAL CONTACT WITH MY BODY.  I UNDERSTAND THAT THE PARTICULAR THERAPEUTIC OUTCOMES OF THESE TREATMENTS CANNOT BE PREDICTED WITH CERTAINTY AND NO GUARANTEE  CAN BE MADE REGARDING ANY PARTICULAR RESULT OR OUTCOME.  I UNDERSTAND THAT A SERIES OF SESSIONS IS RECOMMENDED FOR OPTIMAL RESULTS.  I CERTIFY THAT ALL MEDICAL  INFORMATION ON THE INTAKE FORM IS CORRECT TO THE BEST OF MY KNOWLEDGE. If you have a specific medical condition or specific symptoms, Craniosacral or Manual Lymphatic Drainage therapy may be not recommended.  A letter of clearance for treatment from your primary care provider may be required.  Because Craniosacral or Manual Lymphatic Drainage therapy may be harmful for 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 forget to do so.

 If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure or strokes may be adjusted to my level of comfort.  I further understand that Craniosacral or Manual Lymphatic Drainage therapy should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a qualified medical specialist for any mental or physical ailment that I am aware of.

Michele Tynan Smith reserves the right to cancel, postpone, or terminate treatment whenever deemed it is in the best interest of one or more parties.