Peninsula Medical, Inc. - Online Surveys: Obesity & Lymphedema

Obesity & Lymphedema Survey

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.

We no longer offer free gifts for surveys.

Name:

General Questions

Sex: Female Male

Age:

Height:

Weight:

Waist:

Cancer: Yes No
If yes: What type?
Breast Lung Prostate Melanoma Ovarian Other

Other Medical Problems:

Diabetes: Yes No
    If yes, are you taking medication? Yes No

Heart: Yes No
    If yes, are you taking medication? Yes No

Lung: Yes No
    If yes, are you taking medication? Yes No

High Blood Pressure: Yes No
    If yes, are you taking medication? Yes No

Back Pain: Yes No
    If yes, are you taking medication? Yes No

Joint/Bone Pain: Yes No
    If yes, are you taking medication? Yes No

Describe these or any other type of problems:

Please fill out the measurement chart below. These measurements are very important because they provide a factual basis from which to draw valid conclusions from the remainder of the survey:

Limb Affected:	Left Right Bilateral
Measured In:	Centimeters Inches

This is the Leg Chart. If you do not have leg edema, please skip this chart.

Leg Chart Instructions

Here are a few things to be aware of about measuring:
- Make sure the measuring tape is snug, but not tight.
- Make sure when measuring, the tape is perpendicular with the limb, not at an angle.
- If bilateral, use unaffected columns for left limb and affected columns for right limb.     (Marked left and right in chart below)
- For measurements on the right side of the chart:
    - Measure the largest part of the thigh.
    - Measure the center of the knee cap.
    - Measure the largest part of the calf.
    - Measure the smallest part of the ankle.

UnAffected (Left)	Affected (Right)	Inches from Ankle
		27"

		24"

		21"

		18"

		15"

		12"

		9"

		6"

		3"

		Ankle
		Instep
.	.	.

	UnAffected (Left)	Affected (Right)
.	.	.
Thigh*
.	.	.
.	.	.
.	.	.
Knee
.	.	.
Calf*
.	.	.
.	.	.
Ankle
Instep

*Largest Area

This is the Arm Chart. If you do not have arm edema, please skip this chart.

Arm Chart Instructions

Here are a few things to be aware of about measuring:
- Make sure the measuring tape is snug, but not tight.
- Make sure when measuring, the tape is perpendicular with the limb, not at an angle.
- If bilateral, use unaffected columns for left limb and affected columns for right limb.     (Marked left and right in chart below)
- For measurements on the right side of the chart:
    - Measure the largest part of the bicep.
    - Measure the center of the elbow.
    - Measure the largest part of the calf.
    - Measure the smallest part of the wrist.

UnAffected (Left)	Affected (Right)	Inches from Wrist
		27"

		24"

		21"

		18"

		15"

		12"

		9"

		6"

		3"

		Wrist
.	.	.
		Palm
.	.	.
.	.	.
.	.	.

	UnAffected (Left)	Affected (Right)
.	.	.
.	.	.
Bicep*
.	.	.
.	.	.
Elbow
.	.	.
Forearm*
.	.	.
.	.	.
Wrist
.	.	.
Palm

*Largest Area

The following statements have five possible responses ranging from 0 to NA(not applicable). Possible responses are:
0 - Not at all
1 - A little bit
2 - Somewhat
3 - Quite a bit
4 - Very much
NA - Not applicable

I have a lack of energy
0 1 2 3 4 NA

I have swelling
0 1 2 3 4 NA

Because of my weight, I have trouble meeting the needs of my family
0 1 2 3 4 NA

Because of lymphedema, I have trouble meeting the needs of my family
0 1 2 3 4 NA

I am bothered by the side effects of treatment for cancer
0 1 2 3 4 NA

I am bothered by the side effects of weight
0 1 2 3 4 NA

I am bothered by the side effects of lymphedema
0 1 2 3 4 NA

I am bothered by the treatment for lymphedema
0 1 2 3 4 NA

I feel ill
0 1 2 3 4 NA

I have had infections in the limb with lymphedema
0 1 2 3 4 NA

I have used antibiotics for infections in the limb with lymphedema
0 1 2 3 4 NA

I am forced to spend time in bed
0 1 2 3 4 NA

I feel close to my friends
0 1 2 3 4 NA

I get emotional support from my family
0 1 2 3 4 NA

I get support from my friends
0 1 2 3 4 NA

My family has accepted my lymphedema
0 1 2 3 4 NA

I am satisfied with family communication about my cancer
0 1 2 3 4 NA

I am satisfied with family communication about my weight
0 1 2 3 4 NA

I am satisfied with family communication about my lymphedema
0 1 2 3 4 NA

I feel close to my partner(or person who is my main support)
0 1 2 3 4 NA

Regardless of your current level of sexual activity, please answer the following question. If you prefer not to answer it, please check the box.
I am satisfied with my sex life
0 1 2 3 4 NA I prefer not to answer

I feel sad
0 1 2 3 4 NA

I am satisfied with how I am coping with cancer
0 1 2 3 4 NA

I am satisfied with how I am coping with weight
0 1 2 3 4 NA

I am satisfied with how I am coping with lymphedema
0 1 2 3 4 NA

I am losing hope in the fight against cancer
0 1 2 3 4 NA

I am losing hope in the fight against weight
0 1 2 3 4 NA

I am losing hope in the fight against lymphedema
0 1 2 3 4 NA

I feel nervous
0 1 2 3 4 NA

I worry about dying
0 1 2 3 4 NA

I worry my condition will get worse
0 1 2 3 4 NA

I am able to work (including work at home)
0 1 2 3 4 NA

My work (including work at home) is fulfiling
0 1 2 3 4 NA

I am able to enjoy life
0 1 2 3 4 NA

I have accepted cancer
0 1 2 3 4 NA

I have accepted weight
0 1 2 3 4 NA

I have accepted lymphedema
0 1 2 3 4 NA

I am sleeping well
0 1 2 3 4 NA

I am enjoying the things I usually do for fun
0 1 2 3 4 NA

I am content with the quality of my life right now
0 1 2 3 4 NA

I have numbness or tingling in my hands/arms
0 1 2 3 4 NA

I have numbness or tingling in my feet/legs
0 1 2 3 4 NA

I feel discomfort in my hands/arms
0 1 2 3 4 NA

I feel discomfort in my feet/legs
0 1 2 3 4 NA

I have joint pain or muscle cramps
0 1 2 3 4 NA

I feel weak all over
0 1 2 3 4 NA

I have trouble waking
0 1 2 3 4 NA

My hands/arms are swollen
0 1 2 3 4 NA

My feet/legs are swollen
0 1 2 3 4 NA

I am bothered by the way my arms or legs look
0 1 2 3 4 NA

Comments:

E-mail: