Client Information Form
Name______________________________________________________________
Address____________________________________________________________
City__________________________ State__________ Zip___________________
Email____________________________Telephone_________________________
Date of Birth____________________ Occupation__________________________
Referred by_________________________________________________________
Reason for seeking Lymphatic Enhancement Therapy:
Please circle any items you are currently wearing:
Pacemaker
Hearing Aid
Hairpiece
Other_______________________________
Consent for care:
I understand that Lymphatic Enhancement Therapy is for improving lymphatic flow and
circulation. I have stated all of my known medical information and understand that it is my
responsibility to keep my lymphatic enhancement practitioner informed of any changes in my
health and of any medications I may take in the future. I also understand that lymphatic
enhancement therapy is not a substitute for medical treatment and that I should see a
doctor/health care provider for diagnosis and treatment for any suspected medical problem.
Signature: _________________________________ Date: ____________________
Medical History/Conditions
circle any that apply
Skin Conditions:
Boils Fungal Infections (Athlete’s foot, ringworm, etc.) Herpes Warts Eczema Hives
Psoriasis
Skin Cancer
Allergies__________________
Respiratory System Conditions:
Bronchitis
Emphysema
Cold
Influenza
Lung Cancer
Pneumonia
Sinusitis Tuberculosis Asthma
Chronic Cough Allergies_____________
Endocrine System Conditions:
Diabetes
Hyperthyroidism
Hypothyroidism
Hypoglycemia
Musculoskeletal Conditions:
Fibromyalgia
Osteoarthritis
Sprains/Strains
Osteoporosis
Gout
Rheumatoid Arthritis
Herniated Disc
Carpal Tunnel
Lyme Disease
Reproductive System Conditions:
Cervical Cancer
Ovarian Cancer
Endometriosis Fibroid Tumors
Breast Cancer
Prostate Cancer
Pelvic Inflammatory Disease
PMS
Pregnancy
Nervous System Conditions:
Multipl Sclerosis
Parkinson’s
Bell’s Palsy
Spinal Cord Injury
Stroke
Seizures
Headaches: Migraine Tension Cluster PMS
Stress
Sleep Disorders
Anxiety
Chemical Dependency
Depression
Digestive System Conditions:
Indigestion Constipation/Diarrhea
Reflux Disorder
Stomach Cancer
Ulcers
Appendicitis
Colorectal Cancer
IBS
Ulcerative Colitis
Hepatitis
Gallstones
Allergies______________________________
Circulatory System Conditions:
Anemia
Blood Clot
Hematoma
Leukemia
Clotting or Bleeding Problems
Atherosclerosis
Hypertension (HBP)
Low Blood Pressure
Varicose Veins
Heart Disease
Heart Attack
Heart Failure
Lymph and Immune System Conditions:
Edema
Lupus
Lymphedema
Chronic Fatigue Syndrome
Epstein Barr (Glandular Fever)
Fever
HIV
Urinary System Conditions:
Kidney Stones
Urinary Tract Infection (UTI)
Bladder Cancer
Do you have Breast Implants? Yes/No
If yes, how long have you had them: ________?
Do you have Botox? Yes/No
Please list and explain other conditions/symptoms you had or are having that
concern you: ________________________________________________________
___________________________________________________________________
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