Questionnaire for Lipedema Patients Name Date of diagnosis Date Name of physician making diagnosis Do you also have lymphedema? What areas of the body are affected? Outside of thighs Inner thighs Knees Lower leg from knee to ankles Foot Toes Upper arms Lower arms Back of hands Fingers Buttocks Abdomen When and where did the swelling start? What is your current Height (inches) and Weight (lbs.) Are your affected areas painful to the touch Yes No Do you have pain when you blood pressure is checked or you have a tourniquet applied for a blood draw? Yes No Do you have unusually large bruises after slight bumps? Yes No Swelling by the end of the day or on hot days? Yes No Pain resulting from contact from your clothing? Yes No
Did you notice a change in your legs during or after pregnancy? Yes No Have/Did you had problems with your menstrual periods? Yes No What is your occupation? Thomas F. Wright, MD FACP RVT (Important information to establish a connection between illness and occupation, if applicable) What percent of the day do you spend standing? Sitting Number of pregnancies, the 1 st of which was years ago. Do you have joint problems? Please describe: Have you had previous liposuction? Yes No If yes, please list areas and dates Was the liposuction helpful? Yes NO Please explain Have you had or are you having any of these therapies for lipedema? Rehab or wellness therapy Manual lymph drainage without bandaging Manual lymph drainage with bandaging Compression treatment with compression stockings Compression stockings Recommendation for more athletic activities Consultation on diet Other
If you have joint problems did the problems appear before the large legs or after the large legs? In which activities do you experience a change? Sports Shopping In everyday life In leisure activities (swimming pool example) Other What did you notice? Clothing size change Elastic marks on your legs in the evening Reduction of working ability Change in mood PAST MEDICAL HISTORY: Do you or have you had any of the following conditions? High blood pressure Diabetes Clotting disorders Deep vein thrombosis (DVT) Rheumatic illnesses Lier disease High cholesterol Kidney disease Ehlers-Danlos Dercum s disease Arthritis Other PAST SURGICAL HISTORY: Have you had any of the following? Abdominal surgery Gynecological surgeries
Varicose vein operation Inflammation of the skin Surgeries of the arteries of the legs Injuries. Please describe Other operations MEDICATIONS: Please list current medications and dosages. INCLUDE ALL SUPPLEMENTS AND VITAMINS. Are you taking birth control pills? Yes No ALLERGIES: Do you have allergies to medications or environmentals? Yes No If yes, please list: FAMILY HISTORY: Do close relatives have? Lipedema Heart disease High cholesterol Kidney disease Circulatory problems Blood clotting problems Thrombosis or lung embolism Diabetes Relation:
Thyroid disease High blood pressure Stroke Lipomas SOCIAL HISTORY Are you married? Spouse name Number of children Years of education Do you smoke? Yes No If yes, how much? Do you drink? Yes No If yes, how much? Do you exercise? Yes No If yes, what type and how often? REVIEW OF SYSTEMS Do you have any of the following symptoms? GENERAL NOSE [] Fatigue [] Stuffiness [] Fever or chills [] Discharge [] Weakness [] Itching [] Trouble sleeping [] Hayfever [] Nosebleeds [] Sinus pain SKIN [] Rashes [] Lumps THROAT [] Itching [] Bleeding [] Dryness [] Dentures [] Color changes [] Sore tongue [] Hair or nail changes [] Dry mouth [] Sore throat HEAD [] Hoarseness [] Headache [] Thrush [] Head injury [] Non-healing sores [] Neck pain
EARS NECK [] Decreased hearing [] Lumps [] Ringing in ears [] Swollen glands [] Earache [] Pain [] Drainage [] Stiffness EYES BREASTS [] Vision loss/changes [] Lumps [] Pain [] Pain [] Redness [] Discharge [] Blurry or double vision [] Flashing lights [] Specks [] Glaucoma [] Cataracts RESPIRATORY MUSCULOSKETAL [] Cough [] Muscle or joint pain [] Sputum [] Stiffness [] Coughing up blood [] Back pain [] Shortness of breath [] Redness of joints [] Wheezing [] Swelling of joints [] Painful breathing [] Trauma CARDIOVASCULAR NEUROLOGIC [] Chest pain or discomfort [] Dizziness [] Tightness [] Fainting [] Palpitations [] Seizures [] Shortness of breath with activity [] Weakness [] Difficulty breathing lying down [] Numbness [] Sudden awakening from sleep [] Tingling with shortness of breath [] Tremor
GASTROINTESTINAL HEMATOLOGIC [] Swallowing difficulties [] Easy bruising [] Heartburn [] Ease of bleeding [] Change of appetite [] Nausea ENDOCRINE [] Change in bowel habits [] Heat or cold intolerance [] Rectal bleeding [] Sweating [] Constipation [] Frequent urination [] Diarrhea [] Unusual thirst [] Yellow eyes or skin [] Change in appetite URINARY PSYCHIATRIC [] Frequency [] Nervousness [] Urgency [] Stress [] Burning or pain wit urination [] Depression [] Blood in urine [] Memory loss [] Incontinence [] Change in urinary strength VASCULAR [] Calf pain with walking [] Leg cramping