LYMPHOEDEMA IRELAND

Providing information and support for people with Lymphoedema

One of our objectives is to campaign for improved services and standards of care for people with lymphoedema, including diagnosis and treatment.

To Strengthen our case it would be most helpful if we can show the prevalence and severity of lymphoedema among our members as an indication of the ongoing effect on them. We have the information sought below for a minority of our members and ask you to PLEASE reply to the questions below and return to us as soon as possible as we would like to have this information collected before the open day if possible.

You can complete the form here on our website and submit it directly to us. Alternatively print a copy of the questionnaire, fill it out and post it to us.

Please be assured that we fully respect the requirements of the Data Protection Act and that any use we make of the data will be in the form of totals and percentages and will not be associated with any particular member.

Mr/Mrs/Ms		Address
First name		Address
Surname		Address
Email		County
Sex	Male  Female	Home phone
Date of birth		Mobile phone
How would you like to receive the newsletter?		Paper as now	Email only
Type of Lymphoedema		Primary	Secondary
Family history	None	Mother	Father
	Sister	Brother	Other
Diagnosed by whom/where
Diagnosis method		Visual	Dye
Affected Areas	Right Arm	Right Leg	Trunk
	Left Arm	Left Leg	Face/neck
Are You		Left-handed	Right-handed
Severity
Stage 0 (latent stage)		Stage I (reversible stage)
Stage II (spontaneously irreversible)		Stage III (Extreme)
Level of Ability/disability
Working full time		Working part-time
Studying		Disability pension
Invalidity pension		Other
Therapist
Treatment		Exercise	MLD
Do you use compression hosiery/sleeves etc		Yes	No
Source of Hosiery		Health Professional	Other