Menu

Medical Questionnaire

Medical Questionnaire


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

If you have lymphedema, is it:

Primary (born with lymphedema OR onset during childhood/puberty/adult without an apparent reason)

Secondary (due to cancer surgery or radiation treatment OR resulting from trauma, infection, other surgeries, accident)

If primary:

a.

At what age did lymphedema first occur?

At birth

years old

b.

Do you have a family history of lymphedema?

Yes

No

c.

How many relatives have been affected by lymphedema?

1,2,3,4,5 +

Affected Area:

a.

Arm(s)

Right

Left

Both

None

b.

Leg(s)

Right

Left

Both

None

c.

Other

Face/Neck
Breast(s)
Trunk
Abdomen
Genitalia
Other (please specify):

SURGERY:

Have you had cancer-related surgery?

Yes

No

a.

If yes, type of surgery?

Lumpectomy, Modified Radical Mastectomy, Radical Mastectomy, Gyneciological (Ovarian, uterine, cervical, vulva), Head/Neck, Prostate, Melanoma
If Other, please specify:

b.

Year you had surgery:

c.

Did your surgery include lymph node removal?

Yes

No

Don't know

d.

If so, how many nodes were removed?

1-3,     4-10,       >10,        unknown

e.

Did you have Sentinel Node Biopsy?

Yes

No

Don't know

f.

How long AFTER your surgery did your lymphedema first occur?

month(s) OR year(s)

g.

What therapy did you receive, if any, pre- or post-surgery?

Radiation
Chemotherapy
Hormonal
Other
None

h.

At the time of your surgery, were you informed about the risk of developing LE and risk reduction methods?

Yes

No

i.

Were your limbs measured before surgery to assess baseline limb volume?

Yes

No

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
If Other, please specify:

INFECTION:

Since the first onset of your lymphedema, have you had an infection in the affected limb(s)?

Yes

No

Don't know

a.

If yes, how many times?

1-3 4-9 10 or more

b.

Have you been hospitalized to treat your infection?

Yes

No

c.

If yes, how many times have you been hospitalized to treat your infection?

1, 2, 3-5,  more

d.

Are you currently taking prophylactic (preventive) antibiotics?

Yes

No

Please answer the following questions with respect to your area affected by lymphedema:

a.

Do you currently experience pain?

Yes

No

If yes, how distressing is the pain?

Little - - - - Extreme

b.

Do you experience a poor range of movement?

Yes

No

If yes, how limited is your range of movement?