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.

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Lymphedema: Primary     Secondary

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Age of onset:

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Cause of Lymphedema:

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Extremity: Upper     Lower

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Age of first pregnancy:

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How did first pregnancy affect Lymphedema:

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Age of second pregnancy:

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How did second pregnancy affect Lymphedema:

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Age of third pregnancy:

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How did third pregnancy affect Lymphedema:

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Any additional pregnancies and affect on Lymphedema:

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Did your weight return to your normal weight after the pregnancies? Yes    No

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Additional Comments:

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(Optional) Name: E-mail: