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Sammuella Pry overcame lymphedema through dedication and hard work and is now completing a degree as a social worker at UC Monterey. She is working on a Capstone project and hopes to bring increased understanding of lymphedema to the medical community. As someone who has suffered from lymphedema, her goal is to bring her special understanding of lymphedema together with her training in social work to further the understanding of the problems faced by people with lymphedema. The specific aim of her proj ect is to obtain an understanding of how lymphedema affected your life and how you learn to cope with lymphedema. I think answering the questions can be of great benefit in several ways. Completing this survey will assist Sammi in the pursuit of her degree, but I think it will provide others, including physicians, with vital insights into the problem of lymphedema.

The purpose of this survey is to provide patients, therapists and physicians with valuable information that will help address further needs of Lymphedema patients. The information provided will be written up in a formal report addressing sociological effects of lymphedema.

 Statement of confidentiality: All information in this survey will be used as statistical data only. Any information that identifies an individual person will not be disclosed without prior written approval from the provider.

Instructions: Please answer each question based on the standard answers to the best of your ability. If the question does not apply please proceed to the next question.

Do you have Lymphedema? Yes No
(If no, do not continue with survey.)
Sex: Male Female
Age:
Age at diagnosis of Lymphedema:
Education:
H.S.     Bachelors     Masters     Doctorate     Other    
Occupation(If retired, previous occupation)?
Was the Lymphedema caused by cancer, heart failure, prior surgery, or other?
Please Explain:
Did another event such as an infection or trauma trigger the Lymphedema?
Please Explain:
Describe your feelings at the time you were diagnosed with Lymphedema:
How do you feel about your condition now:
What information did you have available about Lymphedema at the time you were diagnosed:
Is your condition controlled? Yes     No
What methods have you used to treat Lymphedema:
Do you consider your Lymphedema: Very Mild     Mild     Moderate     Severe    
How many times per month do you go out socially with family and friends:
1-3     4-6     7-10     10-13     14-17     17-20     greater then 20    
What support system do you have?
Family     Friends     Support Group     Psychologist
Other:
Are you currently receiving treatment for Lymphedema?
Explain:
Have you had any infections? Yes     No
If you had any infections, how many: 1-3     4-7     8-10     Greater then 10
Which limbs are affected by Lymphedema:
Arm     Leg     Both Arms     Both Legs
What are the measurements of the affected limb(s):
Left  / Right   Left  / Right   
Wrist Ankle
Forearm Calf
Upper arm Thigh
What are the measurements of the unaffected limb:
Left  / Right   Left  / Right   
Wrist Ankle
Forearm Calf
Upper arm Thigh
Do you have support within the medical setting?
Psychologist     Support Group     Counseling Specialist
Other:
Do you have medical insurance? Yes     No
Type:
Private     Medicare     Medi-Cal
Other:
Have you been treated for any psychological issues associated with Lymphedema? Yes     No
Type:
Depression     Anxiety     Isolation
Other:
How far do you travel for treatment/physician:
1-10     10-20     20-30     30-40     40-50     50-60     60-70     70-80     80-90     Over 100
Was your original primary care physician familiar with Lymphedema and treatment of patients with Lymphedema?
Yes     No
How long(in months) was it from onset to diagnosis?
Did you or do you have trouble finding clothing and/or footwear due to your Lymphedema? Yes     No
Have you learned anything about Lymphedema that you think will help others who suffer from Lymphedema?
Please Explain:
(Optional)

Name:
E-mail: