Name * First Name Last Name Preferred pronouns Email * Reason for visit * Are you experiencing diagnosed lymphedema, if so, where? Are you experiencing swelling, if so where? When did this start, or was diagnosed? Have you had surgery? Yes No If yes, please list surgeries and dates. Have you had lymph nodes removed? If so where & when? Have you received radiation for cancer treatment? Have you have chemotherapy treatment? If so when? Are you experiencing pain? If so, where? Are you experiencing any of the following? Asthma Bronchitis Difficulty breathing Heart edema Diabetes Infections Kidney failure Crohns disease Varicose veins Blood clots Please share anything else from above Any ideal outcomes for this visit? Thank you!
