Pre-consultation form

Our online form will help us establish a personalized diagnosis of your lipedema.

Name

First name

E-mail

Phone number

Date of birth

City

Job

Weight (kg)

Size (in cm)

Medication treatment(s)? If yes, please specify

Previous operation(s)? If yes, please specify

History of your weight (changes)

number of children

Disease(s)

Drug treatment? If yes, please specify

Operations carried out

Smoking? if so for how long and how many cigarettes/day

Areas affected by lipedema

Lower limbs Upper limbs

Liposuction of affected areas?

Yes No

If so, when and by which surgeon?

History of your lipoedema (for how long, evolution...)

Is there a history of lipedema in your family?

Do you engage in regular physical activity? If yes, which sport and how much time per week

Do you have a balanced diet?

Yes No

Do you use lymphatic drainage?

For how long?

Has it been effective?

Have you worn compression stockings or tights?

Yes No

Is the affected area painful?

On which areas are the pains present?

Hypersensitivity of affected areas?

Does it itch?

Do you have feelings of heaviness?

Do you have spontaneous bruising on the affected areas?

Is there any swelling?

Is walking limited?

Quality of life due to lipedema?

Aesthetic note of the areas affected by lipedema?