Lymphedema Questionnaire:

First Name *

Last Name *

Email Address *

Home Phone Number *

Part I.

 

A.

Did your breast surgery include lymph node removal?

 

B.

Did you have sentinel node biopsy?

 

C.

Did you receive radiation therapy pre or post surgery?

 

D.

Have you had any infection in your arm on the same side as you had your breast surgery?

   

E.

Are you experiencing any of following symptoms in your arm/hand on the side of where you had surgery?

   

Pain

   

Stiffness

   

Heaviness

   

Swelling

F.

Are you more than 20 lbs overweight?

   

 

G.

Are you 55 years or older?

   

 
 
 

Part II.

 

A.

I have a clear understanding about what causes Lymphedema?

   

 

B.

I am aware of the treatment methods and therapy options for Lymphedema?

   

 

C.

I feel confident in my knowledge regarding Lymphedema symptoms, prevention of Lymphedema, and self-care of Lymphedema.

   

 

 

Questionnaire Purpose:

Due to medical advances, approximately 2.3 million women are now survivors of breast cancer. However, as a consequence of these treatments, many patients will suffer from a secondary disease known as Lymphedema.

Lymphedema, the swelling of arms/chest due to impairment of lymphatic flow, is a disease which develops as a result of the treatment of cancer. Breast cancer related Lymphedema is documented between 33-48 percent of patients following axillary lymph node dissection and radiation therapy and 5-14 percent after sentinel lymph node biopsy and radiation therapy.

Currently, Lymphedema is only diagnosed after arm swelling develops. At this point lymphedema has already begun to progress towards non-reversible stages. The aim of CORAL’s screening tool is to predict the likelihood of developing Lymphedema.

Once identified, Lymphedema prevention strategies and regiments can minimize the costs and complications associated with the later stages of this disease.

Remember, early detection of Lymphedema will enable the most effective and least invasive intervention.