LymphWorks, LLC
2023+ Massage and/or Lymphatic Health History Form
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Personal Info
First Name
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Contact Info
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Source of Referral
Address
City
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Australia
Canada
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Afghanistan
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Bolivia, Plurinational State Of
Bosnia And Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
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C?te D'Ivoire
Cambodia
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Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic Of The
Cook Islands
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
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Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island And Mcdonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic Of
Iraq
Isle Of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People'S Republic Of
Korea, Republic Of
Kuwait
Kyrgyzstan
Lao People'S Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia, The Former Yugoslav Republic Of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States Of
Moldova, Republic Of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Barth?lemy
Saint Helena, Ascension And Tristan Da Cunha
Saint Kitts And Nevis
Saint Lucia
Saint Martin
Saint Pierre And Miquelon
Saint Vincent And The Grenadines
Samoa
San Marino
Sao Tome And Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia And The South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard And Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province Of China
Tajikistan
Tanzania, United Republic Of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks And Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela, Bolivarian Republic Of
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis And Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Province / State
Postal / Zip Code
Emergency Contact
Emergency Contact
Emergency Phone
Relationship
Doctor
Doctor's Name
Doctor's Phone
Doctor's Address
Other
Medical Info
Primary Complaint
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General Health
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Current Treatment
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Past Treatment (from other practitioners)
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Medications
Injuries
Surgeries
Additional Info
Conditions
Health Questions
Warts
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Blood thinner medication
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Gastrointestinal
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Migraines/Headaches
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Cancer
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Hearing Impairment
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Mood Disorder
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Cardiovascular
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Heart Attack
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Pacemaker
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Concussion
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Heart Condition
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Past Heart Surgery
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Congenital Heart Defect
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High blood pressure
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Schizophrenia
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Depression
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HIV/Aids
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Stroke
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Diabetes
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Low blood pressure
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Varicose veins
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Asthma
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Epilepsy
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Meniere Disease
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Vertigo
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Treatment Goals
Improve Well Being
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Pain Relief
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Rehabilitation
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Stress Relief
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Support in Healing/Recovery
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Health Advice for Healing
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Improve Lifestyle
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Improve Symptoms
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Other
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Well Being
Exercise
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Hobbies
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Mobility/Walking Aids
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Smoking
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Sports
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Sugar Intake
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Caffeine
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Supplements
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Drinking
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Water Intake
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Are you currently taking any supplements/Natraceuticals?
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Infectious
Epstein Barr
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Lyme Disease
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Pneumonia
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Strep
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Presence of any infectious condition?
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Emotion / Memory
Alzheimer Disease
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Anxiety Disorder
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Mood Disorder
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Schizophrenia
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Stress
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Substance Use Disorder
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COVID-19 Questionnaire (Check Appropriate Boxes to Comment Below)
Have you tested positive for COVID-19 at Anytime since 2019?
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No Current Flu, RSV, Cold or COVID Symptoms
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Do you have any Long Haul COVID symptoms?
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Oncology
Cancer Type
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Date of Diagnosis
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Location
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Status
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Treatment: Surgery
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Date of Surgery
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Lymph Nodes Removed
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Side Effects of Surgery
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Reconstruction Date
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Treatment: Chemotherapy
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Side Effects of Chemo
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Treatment: Radiation
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Number of Radiation Treatments
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Area of Radiation
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Nodes Irradiated
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Other Treatments
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Medical Devices
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Bone Pain
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Adhesions
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Incision
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Pressure Sensitivity
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Pain
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Former Injuries
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Loss of Movement
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Abnormal Skin Sensation
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Memory Problems
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Edema
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Low Platelet
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Low White Count
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Blood Clot
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Excessively Warm/Cold
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Lymphedema
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Heart Condition
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Lung Condition
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Dry Skin
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Fragile Skin
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Radiation Skin Reaction
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Hair Loss
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Fatigue
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Systemic Infection
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Infectious Condition
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Current Tumour
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Enlarged Lymph Nodes
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Enlarged Spleen
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Enlarged Liver
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Radioactivity
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Area of Complaint
Left Side of Neck
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Right Side of Neck
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Left Side of Upper Back
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Right Side of Upper Back
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Left Side of Mid Back
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Right Side of Mid Back
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Left Side of Low Back
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Right Side of Low Back
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Chest
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Abdomen
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Left Arm
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Right Arm
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Left Shoulder
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Right Shoulder
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Left Elbow
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Right Elbow
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Left Wrist
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Right Wrist
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Left Hand
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Right Hand
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Left Leg
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Right Leg
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Left Hip
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Right Hip
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Left Knee
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Right Knee
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Left Ankle
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Right Ankle
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Left Foot
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Right Foot
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Sacrum
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Tailbone (coccyx)
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Headaches
Migraines
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Headaches
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Cluster
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Rebound
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Sinus
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Chronic Daily Headache
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Tension
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Other Headaches
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Neurological
Brain Injury
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Multiple Sclerosis
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Tingling
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Cerebral Vascular Accident (Stroke)
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Cerebral-vascular Accident
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Stabbing
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Seizure Disorder
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Sciatic Pain
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Stroke
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Loss of Sensation
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Transient Ischemic Attacks (TIA)
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Vertebral and Spinal Cord Injury
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Epilepsy
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Shingles
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Cerebral Palsy
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Huntington Disease
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Dizziness
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Parkinsons
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Shingles / Herpes
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Numbness
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Brain Disorder
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Herniated Disc
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Burning
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Chronic Pain Disorder
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Other Neurological
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Hearing
Conductive Hearing Loss
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Meniere Disease
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Motion Sickness
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Tinnitus
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Vertigo
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Ear Problems
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Hearing Loss
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Kidney
Renal Cysts
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Urinary Incontinence
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Urinary Tract Infection
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Bladder Disorder
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Chronic Kidney Disease
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Congenital Kidney Disease
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Electrolyte Imbalance
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Kidney Stones
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Other Kidney
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Blood
Hypercoagulability
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Hepatitis
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Polycythemia
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Haemophilia
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HIV
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Thrombosis/Embolism
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Blood Thinner Medication
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Anemia
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Stroke
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Bleeding Disorder
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HIV/AIDS
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Other Blood
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Gastrointestinal
Digestive Conditions
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Constipation
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Poor Appetite
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Diarrhea
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Crohn's Disease
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Stomach Disorder
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Diverticulitis
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Ulcerative Colitis
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Eating Disorder
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Esophageal Disorder
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Fecal Impaction
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Celiac Disease
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Intestinal Polyps
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Irritable Bowel Syndrome
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Other Gastrointestinal
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Reproductive
Menstrual Cycle Disorder
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Ovarian Cysts/Tumors
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Pelvic Inflammatory Disease
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Premenstrual Syndrome
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Pregnancy
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Breast Disorder
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Uterine Disorder
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Gynaecological Conditions
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Ectopic Pregnancy
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Endometriosis
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Menopause
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Other Reproductive
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Immune
Non-Hodgkin Lymphoma
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Rheumatoid Arthritis
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Anaphylaxis
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Allergies
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Lupus
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Hodgkin Lymphoma
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Cancer
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Infectious Mononucleosis
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Leukemia
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Other Immune
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Skin
Athlete's Foot
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Acne
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Psoriasis
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Allergic Dermatosis
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Rash
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Herpes
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Hypersensitive Reaction
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Athletes Foot
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Rosacea
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Bruise Easily
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Chemical Burn
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Cosmetic Surgery
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UV Burn
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Melanoma
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Hypersensitive Reactions
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Eczema
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Melanoma/Carcinoma
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Infectious Skin Conditions
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Pigmentary Disorder
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Skin Conditions
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Skin Irritations
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Plantar's Wart
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Other Skin
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Musculoskeletal
Chronic Myofascial Pain Syndrome
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Hereditary/Congenital Deformity
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Strain/Sprain
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Degenerative Disk Disease
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Joint Injury
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Amyotrophic Lateral Sclerosis (ALS)
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Osteoporosis
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Plantar Fasciitis
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Osgood-Schlatter Disease
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Osteoarthritis
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Muscular Dystrophy
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Gout
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Ankylosing Spondylitis
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Spasms / Cramps
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Osteomalacia
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Myasthenia Gravis
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Tendonitis/Bursitis
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Bone Disease
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Whiplash
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Paget Disease
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Sinus Problems
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Broken Bone / Fracture
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Compartment Syndrome
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Artificial Joints / Special Equipment
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Psoriatic Arthritis
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Carpal Tunnel Syndrome
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Dislocation
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Scleroderma
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Fibromyalgia
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Arthritis
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Jaw Pain (TMJD)
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Chronic Fatigue Syndrome
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Fracture
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Scoliosis
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Other Musculoskeletal
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Cardiovascular
Varicose Veins
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Congenital Heart Defect
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Heart Attack
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Cardiovascular Conditions
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Blood Pressure
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Acute Coronary Syndrome
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Blood Clots
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Coronary Artery Disease
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Phlebitis
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Aneurysm
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Lymphedema
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Hyperlipidemia
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Angina
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Pericarditis
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Cardiovascular Accident
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Atherosclerosis
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Raynaud Disease
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Cold Hands
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Pacemaker
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Cardiac Arrhythmia
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High Blood Pressure
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Rheumatic Heart Disease
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Cold Feet
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Heart Disease
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Chronic Ischemic Heart Disease
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Low Blood Pressure
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Valve Disorders
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Swelling
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Myocardial infarction
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Chronic Venous Insufficiency
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Congestive Heart Failure
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Other Cardiovascular
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Respiratory
Chronic Cough
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Shortness of Breath
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Sinus Problem
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Respiratory Conditions
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Asthma
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Tuberculosis
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Emphysema
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Bronchitis
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Respiratory Tract Infection
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COPD
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Infectious Respiratory Conditions
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Cystic Fibrosis
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Other Respiratory
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Endocrine
Acute Pancreatitis
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Diabetes
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Hyperthyroidism
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Hypothyroidism
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Prostate Condition
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Pituitary and Growth Disorder
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Other Endocrine
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Family History
Arthritis
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Cardiovascular
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Respiratory
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Miscellaneous
Vision Problems
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Vision Loss
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Mental Health Issues
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Surgical Pins or Wire
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Insomnia
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Liver Disease
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Weakened Immune Function
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Other Medical Conditions
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Other Diagnosed Diseases
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Massage Goals
Increase Well-Being
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Injury Rehabilitation
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Address Health Issues
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Pain Relief
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Alternative Therapy
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Positive Reinforcement
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