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Lipoedema Consultation Form
Vasu Karri
2023-01-16T20:04:53+00:00
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.
Name
(Required)
First
Last
Email
(Required)
Date of Birth
(Required)
Day
Month
Year
When are you due to have your consultation with Mr Karri?
(Required)
Day
Month
Year
At what age did you first notice a change in your legs?
(Required)
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
Yes
No
Any additional information you wish to add?
Can you slim down your legs with diet and/or exercise?
Yes
No
Any additional information you wish to add?
Do you have pain / tenderness in the fat on your legs?
Yes
No
Any additional information you wish to add?
Do you suffer pain / discomfort if pressure is placed on your legs?
Yes
No
Any additional information you wish to add?
Have you ever dislocated your kneecap(s)?
Yes
No
Any additional information you wish to add?
Have you ever had treatment for varicose veins?
Yes
No
Any additional information you wish to add?
Does the skin on your legs feel cold to touch?
Yes
No
Any additional information you wish to add?
Do you have poor hair growth on your legs?
Yes
No
Any additional information you wish to add?
Do you find it difficult to tan your legs?
Yes
No
Any additional information you wish to add?
Does anyone else in your family have large legs?
Yes
No
Any additional information you wish to add?
Do you have difficulty finding clothes / footwear to fit?
Yes
No
Any additional information you wish to add?
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?
(Required)
No
Yes
If so, how much?
Sign
Signature
(Required)
Date
(Required)
DD slash MM slash YYYY
Checking you’re real
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