Welcome To Haladay Physical Therapy

First Name *

Last Name *

Email *

Phone *

Have You Had Therapy Before For Lipedema or Lymphedema? *

Yes

No

If you answered yes above, where?

Are you currently wearing compression garments?

Yes

No

Sometimes

Do You Have Pain or Heaviness/Fullness?

Yes

No

Where Does It Hurt?

Rate Your Pain/Discomfort on a scale of 0 to 10 (0 being no pain, 10 being you need to go to the ER)

Where did you hear about us? (Google, Physician Name, Website, Local Event, Etc) *

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