NAME *

First Name

Last Name

PHONE *

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Primary reason/s for booking MLD or Rasa-Abhyanga? *

Select one or more

General Wellness, Self-care, Relaxation

Detox and other health benefits

Advised by a doctor or therapist

For healing after recent surgery / cosmetic surgery

For treating oedema, edema

Any current or recent malignant disease conditions? *

Yes

No

Any current or recent acute inflammation or infection caused by bacteria, fungi, chemicals etc? *

Yes

No

Any current or recent allergy episodes: pollen, food etc? *

Yes

No

History of acute deep vein thrombosis and/or phelbitis? *

Yes

No

Current or any history of cardiac insufficiency or heart disease? *

Yes

No

Current or any history of bronchial asthma that requires regular medication? *

Yes

No

Current or history of auto-immune condition related to body organs like liver, kidney etc? *

Yes

No

Do you have insulin dependent diabetes? *

Yes

No

Are you on immuno-suppressants? *

Yes

No

Do you have any oedemas of unknown origin or which are not checked by a GP? *

Yes

No

Current or any history of low blood pressure? *

Yes

No

Current or any history of thyroid disorders managed by medications? *

Yes

No

Do you have rheumatoid arthritis? *

MLD can not be given in active flare-up.

Yes

No

History of significant chronic infection/s? *

Yes

No

Are you within 2-3 days on either side of your menstruation cycle? *

Yes

No

Can you be pregnant or in first trimester? *

MLD can only be given after first trimester and if there are not any complications with the pregnancy.

Yes

No

Are you diagnosed with endometriosis, cysts or any other uterine condition? *

Yes

No

Do you have any dental condition like toothache or acute infection? *

Yes

No

Do you have any nevus that are not checked by a GP? *

Yes

No

Do you have lymphedema, phlebedema, lipedema or similar conditions? *

Please note we do not treat these conditions. We can direct you to a local MLD therapist and issue full refund of the amount paid.

Yes

No

History of trauma or abuse *

Yes

No

BOWEL MOVEMENT

2-3 times a day

Once a day

Variable each day

3-4 times a week

High constipation

Does not feel fully emptied

BODY-WEIGHT

Underweight

Overweight

Often fluctuating

Prefer losing some body-fat

At optimal weight

Don't care

DAILY ENERGY LEVELS

Exhausts quickly

Exhausts from excessive thinking

Always low

Frequent fatigue

Always high

HEALTH GOALS (Select Top 5)

Recovery from existing physical / mental health condition (Pl provide details below if wish)

Detox and cleansing

Hormonal balance

Fertility

Menstrual health

Delay ageing, better skin health

Weight management / body-fat reduction / fitness

Stress/ anxiety reduction / management

Re-balance, re-align, reset

Immunity / vitality / energy

Pain relief and management

Strength and flexibility

Improving digestion

Better diet and healthier lifestyle

Sleep enhancement

Sexual / reproductive health

Overcoming trauma, distress, suppressed emotions

Better control over thoughts and emotions

Freedom from habits, addictions, limitations

Improvement in relationship with self

Improve relationship with others

Spiritual balance / connection

Start some form of Meditation / Breath-work

Other goals (Pl mention below)