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​Pregnancy Lymphatic Drainage Intake Form

Welcome to The Radiance Space


It is a joy to welcome you. To ensure your comfort, well-being, and safety during this special stage of your life, please take a moment to complete this pregnancy intake form. The information you provide is confidential and will help us adapt your treatments to your current needs, offering you a safe and personalised experience.

Date of your birth
Day
Month
Year

Pregnancy Information

Baby's due date
Day
Month
Year
Is this your first pregnancy?
Yes
No
Is your pregnancy considered high-risk?
Yes
No
Do you have medical clearance to receive lymphatic drainage?
Yes
No
Are you attending regular prenatal check-ups?
Yes
No

Current Symptoms & Care

Do you sit for long hours at work, computer or driving?
Yes
No
Do you experience swelling in any of the following areas?
Do you feel pain or heaviness in your legs?
Yes
No
Do you wear compression stockings?
Yes
No
Do you experience shortness of breath or dizziness with light activities?
Yes
No
Do you experience back or pelvic pain?
Yes
No
Please indicate if you currently have or have had any of the following conditions:

Terms & Conditions

I commit to following all the instructions provided to me. I also express my agreement and willingness to undergo the proposed treatment, assuming responsibility for any possible undesirable effects.
I agree
I confirm that the information provided is accurate to the best of my knowledge. I understand that lymphatic drainage is not a substitute for medical care and that treatments will be adapted to my individual condition.
I agree

Find Us

Level 1 - Suite 1.07

685 Pittwater Rd, Dee Why 2099, NSW

Working hours

Monday 9am - 7pm

Tuesday 9am - 7pm

Wednesday 9am - 7pm

Thursday  9am - 7pm

Friday 8am - 5pm

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