Your Practice — Manual Lymphatic Drainage (MLD) Consultation

Personal Details

Tell us a little about yourself.

First Name

Surname

Address

Phone

Date of Birth You can type your date of birth (dd/mm/yyyy) or choose it from the calendar.

GP name & surgery

Emergency contact name

Emergency contact phone

Relationship to you

Treatment context

What is the main reason for requesting MLD?

Diagnosed lymphoedema

Persistent swelling or oedema

Following cancer treatment

Following surgery

Wellbeing or relaxation

Other

Please describe the reason for treatment and the areas affected

Relevant diagnosis (if any)

Referring clinician, lymphoedema service or specialist details (if applicable)

Swelling and lymphatic history

Which areas are swollen or affected?

When did the swelling or symptoms begin?

Describe changes during the day and anything that improves or worsens the symptoms

Have you had lymph nodes removed or treated?

Yes No

Have you received radiotherapy to or near the affected area?

Yes No

Previous MLD, SLD, compression or lymphoedema treatment

Safety screening — please tick any that currently apply:

Current infection, cellulitis, fever or feeling acutely unwell

Known or suspected blood clot / DVT

New, sudden or unexplained swelling

Heart failure or another significant heart condition

Kidney disease or impaired kidney function

Active cancer or current cancer treatment

New breathlessness or chest pain

Open, weeping or unhealed wound in the treatment area

Pregnant or recently given birth

Health, medication and skin

Relevant medical history, operations and hospital treatment

Current medication, including anticoagulants or antibiotics

Allergies or skin sensitivities

Skin condition in the proposed treatment area, including redness, heat, broken skin or leakage

MLD consent

MLD is a specialised, gentle technique. This form supports practitioner screening and does not diagnose the cause of swelling or replace medical assessment. Treatment may be postponed and medical advice requested where safety concerns are identified.

Data Protection (UK GDPR)

I hereby declare that the details are true and correct to the best of my knowledge and I undertake to inform you of any changes immediately. I have read and acknowledged the Privacy/GDPR policy. Thank you kindly for visiting us today and completing this form. Hope to see you again soon.

Client Signature

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Date

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Manual Lymphatic Drainage (MLD) Consultation

Personal Details

Treatment context

Swelling and lymphatic history

Safety screening — please tick any that currently apply:

Health, medication and skin

MLD consent

Data Protection (UK GDPR)

Client Signature

Age Restriction

Additional Information