Lavelle Health — Manual Lymphatic Drainage

About you

Full name

Your copy of this form will be sent here.

Phone

Date of birth

Optional — helps Rae keep accurate records.

Home address

Emergency contact — name

Emergency contact — phone

How did you hear about Rae?

Your visit

What brings you in?

Choose everything that applies.

Anything else Rae should know about what you’re hoping to get out of your sessions?

Have you received manual lymphatic drainage before?

YesNo

Health screening

Lymphatic drainage is very gentle, but a few conditions need extra care — or a doctor’s okay — first. Please answer honestly: a “Yes” doesn’t necessarily mean you can’t receive treatment, it just tells Rae what to take into account.

Do you currently have a fever, an infection, or feel generally unwell?

YesNo

Please give a few details

Do you have a heart condition?

For example congestive heart failure, an arrhythmia, or a recent cardiac event.

YesNo

Please give a few details

Any history of blood clots, DVT, or a clotting disorder?

YesNo

Please give a few details

Any kidney problems?

YesNo

Please give a few details

Are you currently being treated for cancer, or do you have a history of cancer?

YesNo

Please give a few details

Have you ever received chemotherapy or radiation therapy?

YesNo

What for, and roughly when?

Are you currently pregnant?

YesNo

How far along are you?

Do you have low blood pressure?

YesNo

Please give a few details

Do you have asthma or another respiratory condition?

YesNo

Please give a few details

Do you have a thyroid condition?

YesNo

Please give a few details

Do you have diabetes?

YesNo

Please give a few details

Any skin conditions, rashes, or open wounds at the moment?

YesNo

Please give a few details

Have you had surgery in the last 3 months?

YesNo

What surgery, and when?

Have you had any other surgeries in the past?

YesNo

Which surgeries, and roughly when?

Have you ever had lymph nodes removed?

YesNo

Please give a few details

Any other medical conditions, or recent changes in your health?

YesNo

Please give a few details

Current medications (if any)

Allergies (if any)

Consent

Manual lymphatic drainage (MLD) is a light, rhythmic massage technique that encourages the natural flow of lymph fluid. Your practitioner is Raegan Brumer — “Rae” throughout this form. Sessions are gentle and non-invasive, and take place at Rae’s home studio. Please read and tick each statement.

May Rae also keep an electronic copy of this form on file?

Printed copies are kept with her client records either way.

Yes — keep my record stored electronically.No — keep printed copies only. The online record is removed automatically after 30 days (long enough to print it).

Signature

Typing your name below signs this form electronically: it confirms you filled it in yourself and agree to the statements above. If the client is under 18, a parent or guardian must complete and sign it.

Type your full name to sign

Today’s date, recorded with your submission: June 10, 2026

Your answers go only to Rae, and a copy is emailed to you at the address you provide. They’re kept securely for her client records — never shared or used for anything else. You can ask for your record to be updated or deleted at any time.