Contact
Physical Address:
1061 Murray Avenue
San Luis Obispo, CA 93405
(Across from Sierra Vista Hospital)
 Mailing Address:
PO Box 12153
San Luis Obispo, CA 93406

Telephone:
(805) 782-9300

Evaluation Questionnaire

Name
Contact Number
Email
Age
Height
Weight
Male/Female
Occupation
Please list any diagnosis in your health history given by a physician
Do you have Allergies
Arthritis or Inflammatory condition
Asthma
Varicose veins or
      distended capillaries
High/Low Blood Pressure
Do you suffer from heart or kidney failure/compromise? Yes     No
Are your tonsils intact? If not, give age and reason for removal. Yes     No
Age/Reason
Have you ever had surgery; oral included? Yes     No
Please list all surgeries (all surgical incisions will need to be considered for an accurate evaluation).
Have you ever had tissue biopsied? Yes     No
Have you ever been treated for cancer? Yes     No
Have you ever been treated for edema/lymphedema? Yes     No
Do you or have you ever taken diuretics? Yes     No
Do you exercise? Yes     No
What is your family medical history?
Describe your current symptoms
Additional Comments

   


Rebecca Stone
MLD Therapist
1061 Murray Avenue
San Luis Obispo, CA 93405
r@rebeccanmr.com
(805) 782-9300

Consultations are available,
please phone or email for
an appointment
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