Intake Questionnaire



AsthmaDiabetesKidney Disease/Renal FailureAortic/Abdominal AneurysmArterial DiseaseCellulitis or InfectionsHeart AttackCOPDArthritisCongestive Heart Failure/CHFHigh Blood Pressure/HTNRheumatoid ArthritisHerniaSpinal Cord InjuryLiver DiseaseDiverticulitisColitisStroke/TIACancerOsteoporosisOrthopedic problemsBipolar disorderDepressionOther



MastectomyReconstructionLumpectomy



No known allergiesLatex allergyOther allergies



YesNo



YesNo



YesNo



YesNo



YesNo



YesNo


YesNo



YesNo



YesNo


YesNo



YesNo


YesNo


Elevation of swollen limbExerciseSurgeryCompression stockings/SleeveCompression pumpAntibioticsManual Lymphatic DrainageCompression bandagingPROFORETraditional massageDiuretics (“water pills”)Unaboot



ZELODADOXILDOXYROBICINADRIAMYOSIN(RED DEVIL)


YesNo



I live aloneI live with a spouse/significant otherI live in an Assisted Living or Independent Living CenterI live in a Nursing HomeI am the caregiver for a spouse/family memberI am fully independent in my daily activities.I require assistance with bathing/dressing



CigarettesChewing Tobacco/DipE-cigarettes


Over the past-two weeks, how often have you been bothered by any of the following problems?


Not at AllSeveral daysMore than half of daysNearly every day


Not at AllSeveral daysMore than half of daysNearly every day


Not at AllSeveral daysMore than half of daysNearly every day


Not at AllSeveral daysMore than half of daysNearly every day


Not at AllSeveral daysMore than half of daysNearly every day


Not at AllSeveral daysMore than half of daysNearly every day


Not at AllSeveral daysMore than half of daysNearly every day


Not at AllSeveral daysMore than half of daysNearly every day


Not at AllSeveral daysMore than half of daysNearly every day



YesNoNo answer


YesNoNo answer


YesNoNo answer


YesNoNo answer


YesNoNo answer




Doctor's officePhysical or Occupational TherapistFriend/relative who received treatment hereOther

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