QUESTIONNAIRE

Your responses to the questions below are important to us.

Please complete the contact information - name, address, phone, email, so we may respond to your inquiry in a timely manner. All of the information given will be kept strictly confidential and used only for our records.

All applicable questions should be answered as completely as possible. This will help us in providing you with information on the services that we offer that will best address your condition.

Thank you.

Name:
Address:
City:
State:
Zip Code:
Home Phone:
Office Phone:
Email Address:
From our web page of services, what modality are you interested in:
What condition are you experiencing? Be specific as possible:
Who diagnosed this condition?
How were you referred to us?
Name of your insurance carrier?
If you have had a post-surgical swelling from either breast / cervical or prostate cancer surgery, a lumpectomy, hysterectomy or other surgery including cosmetic augmentation such as breast or liposuction OR swelling for no apparent reason, please continue.

Please describe the affected area (Example:Leg /Arm/Other) and include pain level 1-10, 1 being least painful, redness of skin, indentation (pitting) of skin, discoloration or fungus of skin, etc.:
Please indicate which best describes your condition. Primary (born with it, or onset during childhood, at puberty or as an adult, but for no apparent reason)

Secondary (due to surgery or radiation treatment, or resulting from trauma, infection or other incident)
What do you think caused the onset of your condition?
Please list all previous or current treatment protocols you have done, are doing or are interested in doing for your condition.

Pumps
Garments
Manual Lymph Drainage
Compression Bandaging
Instruction in Self-Care
Exercise(s)
Nutrition
Alternative Approaches
Other-not listed, please list

Are you wearing garments? Yes    No
Who measured and fitted you for your compression garment(s)?
What garment manufacturer are you wearing?

Other:

Are you following a daily self-care program? Yes   No   Not Applicable
If yes, please click all that apply. Self-MLD
Bandaging
Skin Care
Exercise/s Garments
How long after your surgery did your lymphedema onset?

Months
Years