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Get St. Mary Lymphedema Intake Form

__ ______________________________________  If you have a history of cancer:              Type:_________________________________  Location:___________________________  Surgery?  Yes  /   No      If surgery, type of surgery/date(s):_______________________________________  Reconstruction? Yes  /   No  Lymph nodes removed?  Yes  /   No     _____ # of nodes removed     _____# of nodes positive for cancer  Have you had:  Che.

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