ALT Questionnaire

ASSISTED LYMPHATIC THERAPY (ALT) QUESTIONNAIRE
IMPORTANT: This Current Conditions Questionnaire is mandatory before booking your first ALT treatment. In certain circumstances, ALT therapy is contraindicated.

STEP ONE: Please read the Rightway Health and Wellness article linked here before proceeding with health history and current conditions form below.
Click Here for link: drive.google.com/file/d/1GimZa-O7J7ndwDzwtywB1V99WmwEd9hf/view

I have read and understand the Rightway Health and Wellness Article, Contraindications and other information provided within. *

Yes, I understand, agree and will comply No, I have not read it.

ALT QUESTIONAIRRE - CURRENT CONDITIONS
Check all that apply and provide answers to all questions.

* Indicates required field

First and Last Name *

Have you had any lymph nodes removed? *

Have you ever been diagnosed with Lymphedema? *

Are you currently under the care of a physician for any specific conditions? If so, list all conditions, or mark N/A. *

If you are under care for any conditions above, please provide the name of your practitioner or mark N/A. *

Have you had any vaccines in the last three weeks? If so, mark Yes and the date, and let's give your immune system one more week before an ALT session to integrate the information. If none, mark N/A. *

Many clients will start to notice visible changes occurring in their bodies after 2-3 treatments. Using your phone, I can take a picture for you so that you can compare those changes at home. Would you like me to take a picture of you with your phone? *

ALT PREPARATION
For best results from your treatment, follow these steps

ONE DAY BEFORE ALT TREATMENT
It is very important to hydrate, by drinking ½ of your body weight in ounces of water.
Use this formula and example as your guide.

Formula: Your body weight /2 = __ oz of water, then /8 oz. = the approximate glasses of water per day.

Example: You weigh 140 pounds, so you would drink 70 ounces of water or approx. 9 glasses. (140 divided by 2 = 70 oz. of water, then divided by 8 oz. = approximately 9 glasses of water)

DAY OF ALT TREATMENT

Avoid using deodorant
Avoid using body lotion
Wear cotton underwear if possible (to avoid compression of the lymph in your hips)

AFTER ALT TREATMENT

Drink ½ of your body weight in ounces of water for 2-3 days after your treatment (See the above formula)

FOR OPTIMAL RESULTS, CONSIDER ADDING THESE TO YOUR ROUTINE

Walking
Dead Sea Salt foot soaks or baths
Electrolytes or trace minerals
Avoid alcohol for 2-3 days

NOTES OR QUESTIONS ABOUT ALT *

Health Disclosure and Appointment Cancellation Policy Agreement

A massage therapist must be aware of any existing physical conditions that I have, I have listed all my known medical conditions and physical limitations and will inform the massage therapist in writing of any change in my physical health. I understand that a massage therapist does not diagnose illness, disease, or any other medical, physical, or emotional disorder, nor do they perform any spinal manipulations or claim to cure disease and illness.
I am responsible for consulting a qualified physician for any physical ailment that I have prior to seeking massage or other modality therapy from Ayaa Massage/My Lighted Life.
I have disclosed all necessary health information, understand the preparation and follow up instructions, and agree to ALT treatment.
If I cancel within 24 hours of my scheduled appointment and, I agree to pay the full dollar amount of my appointment.
I understand I can find HIPAA disclosure information related to my healthcare through this link provided by the U.S. Dept of Health and Human Services: www.hhs.gov/hipaa/for-individuals/index.html
I agree that by typing or signing my name on this form, and/or submitting this form that it will represent my willful and legal signature for this document, and booked therapy.

Date *

I certify that the above health history is correct, and I agree to the policies set forth within this intake document by typing or signing my name here *

Submit

New Client Form

ASSISTED LYMPHATIC THERAPY (ALT) QUESTIONNAIRE
IMPORTANT: This Current Conditions Questionnaire is mandatory before booking your first ALT treatment. In certain circumstances, ALT therapy is contraindicated.

ALT QUESTIONAIRRE - CURRENT CONDITIONS
Check all that apply and provide answers to all questions.

ALT PREPARATION
For best results from your treatment, follow these steps

Health Disclosure and Appointment Cancellation Policy Agreement

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New Client Form

ASSISTED LYMPHATIC THERAPY (ALT) QUESTIONNAIRE​IMPORTANT: This Current Conditions Questionnaire is mandatory before booking your first ALT treatment. ​In certain circumstances, ALT therapy is contraindicated.

ALT QUESTIONAIRRE - CURRENT CONDITIONSCheck all that apply and provide answers to all questions.

ALT PREPARATION For best results from your treatment, follow these steps

Health Disclosure and Appointment Cancellation Policy Agreement

Watch, Like , Subscribe and Connect on our Socials!

ASSISTED LYMPHATIC THERAPY (ALT) QUESTIONNAIRE
IMPORTANT: This Current Conditions Questionnaire is mandatory before booking your first ALT treatment. In certain circumstances, ALT therapy is contraindicated.

ALT QUESTIONAIRRE - CURRENT CONDITIONS
Check all that apply and provide answers to all questions.

ALT PREPARATION
For best results from your treatment, follow these steps