Lipoedema Consultation Form

This form will take approximately 5-10 minutes to complete.

Please take the time to answer the below questions as accurately and honestly as you can. All questions must be answered prior to your consultation with Mr Karri.

At what age did you first notice a change in your legs? *

Have your legs got worse since then? If so, how?

Do you bruise easily? E.g. develop a bruise but don't know how it happened

YesNo

Can you slim down your legs with diet and/or exercise?

YesNo

Do you have pain / tenderness in the fat on your legs?

YesNo

Do you suffer pain / discomfort if pressure is placed on your legs?

YesNo

Have you ever dislocated your kneecap(s)?

YesNo

Have you ever had treatment for varicose veins?

YesNo

Does the skin on your legs feel cold to touch?

YesNo

Does anyone else in your family have large legs?

YesNo

Do you have difficulty finding clothes / footwear to fit?

YesNo

Have you had any previous treatments on your legs? E.g. manual lymphatic drainage (MLD) or surgery

What surgery have you had in the past and when?

Do you have any medical problems? e.g asthma, diabetes? Etc

What medications do you take?

Are you allergic to any medications?

Do you smoke? *

NoYes