Manual Lymphatic Drainage

Name *

First Name

Last Name

Phone

(###)

###

####

Do you currently experience swelling/lymphedema? (Please Check all that apply. )? *

Right Arm

Left Arm

Both Arms

Breast

Right Leg

Left Leg

Both Legs

Genital

Head and Neck

Have you had a previous treatment for swelling/lymphedema? If yes, check all that apply.

Manual Lymphatic Drainage

Compression Bandaging

Lymphedema Exercise

Compression Pump

Flexitouch

Low Level Laser

Compression Garments