Questionnaire

None of the information is required.

If you don't want to supply your name, email address, or anything else, just leave those sections blank. Your name and email address (items in green) will not be published or given to any third party without your prior consent. They will only be used if there is a need to contact you about your questionnaire submission.

All other information submitted may be published on these web pages and can therefore be viewed by others. We ask that you please fill in as much information as you can. The more data you enter, the more information will be available to search through, making the database more valueable to everyone.

If you have had experiences with more than one insurance company or clinic, fill out and submit the form once for each. After submitting, click your "back" button to return to the form to avoid having to retype everything.

I would like thank our helper, "Susan", for generously donating her time in handling the submitted questionnaires and storing them into the database. Thank you Susan!

And now, with no further ado, here is the questionnaire ...

INFORMATION ABOUT YOURSELF Name City State/Province (Use two char abbreviations please) Country EMail What year were you born? (use 4 digits please) What is your gender? What type of lymphedema do you have? What year did you first get lymphedema? (use 4 digits, please) INFORMATION ABOUT YOUR INSURANCE COMPANY Name of insurance company Address City State Country Phone Do they pay for MLD/CDP/etc.? Do they pay for supplies? Do they pay for compression garments? Do they pay for bandages? CLINIC INFORMATION This section is for those who have visited a lymphedema clinic, therapist or hospital. We use the term "clinic" here to refer to any clinic, hospital, therapist or other caregiver or institution. Name of clinic City State/Province (Use two char abbreviations please) Country How would you rate this clinic? (1 to 10, 10 = best) Other information about this clinic that you'd like to provide: When you're done, press "Send". Please press it only once even if it takes a while to respond.