Please select the response that most accurately describes you: |
I am a person with Lymphoedema I am a family member of a person with lymphoedema I am a person at risk of lymphoedema |
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If you have lymphedema, is it: |
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Primary (born with lymphedema OR onset during childhood/puberty/adult without an apparent reason) |
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Secondary (due to cancer surgery or radiation treatment OR resulting from trauma, infection, other surgeries, accident) |
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If primary: |
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a. |
At what age did lymphedema first occur? |
At birth |
years old |
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b. |
Do you have a family history of lymphedema? |
Yes |
No |
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c. |
How many relatives have been affected by lymphedema? |
1,2,3,4,5 + |
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Affected Area: |
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a. |
Arm(s) |
Right |
Left |
Both |
None |
b. |
Leg(s) |
Right |
Left |
Both |
None |
c. |
Other |
Face/Neck |
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SURGERY: |
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Have you had cancer-related surgery? |
Yes |
No |
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a. |
If yes, type of surgery? |
Lumpectomy, Modified Radical Mastectomy, Radical Mastectomy, Gyneciological (Ovarian, uterine, cervical, vulva), Head/Neck, Prostate, Melanoma |
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b. |
Year you had surgery: |
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c. |
Did your surgery include lymph node removal? |
Yes |
No |
Don't know |
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d. |
If so, how many nodes were removed? |
1-3, 4-10, >10, unknown |
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e. |
Did you have Sentinel Node Biopsy? |
Yes |
No |
Don't know |
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f. |
How long AFTER your surgery did your lymphedema first occur? |
month(s) OR year(s) |
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g. |
What therapy did you receive, if any, pre- or post-surgery? |
Radiation |
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h. |
At the time of your surgery, were you informed about the risk of developing LE and risk reduction methods? |
Yes |
No |
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i. |
Were your limbs measured before surgery to assess baseline limb volume? |
Yes |
No |
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If you did NOT have cancer surgery, what do you think caused the onset of your Lymphedema? |
Infection, Trauma (Injury), Post surgery (not cancer), Venous insuffiency, Post Childbirth, Filariasis, Liposuction |
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INFECTION: |
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Since the first onset of your lymphedema, have you had an infection in the affected limb(s)? |
Yes |
No |
Don't know |
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a. |
If yes, how many times? |
1-3 4-9 10 or more |
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b. |
Have you been hospitalized to treat your infection? |
Yes |
No |
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c. |
If yes, how many times have you been hospitalized to treat your infection? |
1, 2, 3-5, more |
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d. |
Are you currently taking prophylactic (preventive) antibiotics? |
Yes |
No |
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Please answer the following questions with respect to your area affected by lymphedema: |
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a. |
Do you currently experience pain? |
Yes |
No |
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If yes, how distressing is the pain? |
Little - - - - Extreme |
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b. |
Do you experience a poor range of movement? |
Yes |
No |
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If yes, how limited is your range of movement? |