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?	Little - - - - Extreme
c.	Do you experience numbness?	Yes	No
	If yes, how distressing is the numbness?	Little - - - - Extreme
d.	Do you experience stiffness?	Yes	No
	If yes, how distressing is the stiffness?	Little - - - - Extreme
e.	Do you experience a feeling of heaviness?	Yes	No
	If yes, how distressing is the heaviness?	Little - - - - Extreme
f.	Have you experienced swelling ?	Yes	No
	If yes, it is:	Mild, moderate, severe
	If yes, do you have swelling:	now, in the last 30 years, in the last year
g.	Have you experienced pain in the last 30 days?	Yes	No
SELF-CARE:
Are you following a daily self-care program for lymphedema?		Yes	No
a.	If yes, what do you do? (check all that apply):	Self-Manual Lymph Drainage Bandaging Compression Garments Skin Care Exercise
b.	How many minutes a day (on average) do you spend on self-care activities for lymphedema?	<30 min 30-60 minute > 60 min
Have you ever undergone an intensive treatment program which includes Complete Decongestive Therapy (CDT) or Manual Lymph Drainage (MLD)?		Yes	No	Don't know
Do you use Alternative Treatments?		Yes	No
a.	Check which ones you use or have used:	Pumps Bandage alternatives Yoga Herbal substitutes Medications - please list: Other
b.	Are any of these MORE effective than CDT?	Yes	No	Don't know
c.	If yes, which one?
Quality Of Life:
a.	My overall quality of life is affected by my lymphedema:	Not at all - - - - A great deal
b.	Over the last 2 months I would rate my overall quality of life as:	Poor - - - - Excellent
Please answer the following questions:
a.	I have a clear understanding about what causes lymphedema	Not at all - - - - A great deal
b.	I am aware of the treatment methods and therapy options for lymphedema	Not at all - - - - A great deal
c.	I am knowledgeable about lymphedema self-care methods	Not at all - - - - A great deal
INSURANCE ISSUES:
Does your insurance provider cover treatment for lymphedema?		Yes	No	Don't know
a.	If yes, type of insurance:	HSA Bupa Others
b.	Which of the following is covered? (check all that apply)	Complete Decongestive Therapy (CDT) Manual Lymph Drainage Bandages Garments Exercise Pumps Don’t know
c.	How many weeks of treatment (1 session/day) by a trained therapist are covered each year?	1 week, 2 weeks, 3 weeks, 4 weeks, 5 or more weeks, Don't know
	OR How many single treatment sessions by a trained therapist each year?	1-5 sessions, 6-10 sessions 11-20 sessions More than 20 Don't know
d.	How many garments are covered each year?	1 2 3 4 5 and more Don't know
e.	How many sets of bandages are covered each year?	1 2 3 4 5 and more Don't know
What do you see as the most pressing issues in lymphedema? (Please check only three for your entry to qualify)		Patient Education Physician/Health Care Professional Education Insurance Reimbursement Standardizing Treatment & Establishing National Certification for Therapists Inclusion of LE in American Medical School Curriculum Funding for research Educating the General Public Nationwide Legislation Other (please specify):
OPTIONAL DEMOGRAPHIC INFORMATION
a.	In what country do you live?
b.	In what year were you born?
c.	What is your gender?	Male		Female
d.	Please indicate the ethnicity with which you most closely identify:	White British White / Asian White others African, Asian, Latino Others
e.	How many persons reside in your household?
Contact Infomation
a.	First Name:
b.	Last Name:
c.	Address:
d.	Town:
e.	County:
f.	Post Code:
g.	Email:

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Medical Questionnaire