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.

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:
  1. Make sure measuring tape is snug, but not tight.
  2. Make sure measuring tape is perpendicular with the limb, not at an angle.
  3. If bilateral, use unaffected columns for left limb and affected columns for right limb.
    (Marked left and right in chart below)
  4. 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

UnAffected
(Left)


Affected
(Right)
27-in-
24-in- Thigh*
21-in-
18-in-
15-in- Knee
12-in-
9-in- Calf*
6-in-
3-in-
Ankle Ankle
Instep 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:
  1. Make sure measuring tape is snug, but not tight.
  2. Make sure measuring tape is perpendicular with the limb, not at an angle.
  3. If bilateral, use unaffected columns for left limb and affected columns for right limb.
    (Marked left and right in chart below)
  4. 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

UnAffected
(Left)


Affected
(Right)
27-in-
24-in-
21-in- Bicep*
18-in-
15-in- Elbow
12-in-
9-in- Forearm*
6-in-
3-in-
Wrist Wrist
...
Palm Palm
*Largest Area
Which product(s) from Peninsula BioMedical do you currently use?
 (may choose more than one)
ReidSleeve® Classic
OptiFlow® EC
OptiFlow® SC
OptiFlow® CS
OptiFlow® CP
TheCinch®
On a scale of 1 (uncomfortable) to 5 (very comfortable), how would you rate our product(s)?
1 2 3 4 5
 Uncomfortable                            Fair                          Very comfortable
On a scale of 1 (poor) to 5 (excellent), how would you rate our product(s)?
1 2 3 4 5
        Poor                               Average                              Excellent      
How long do you wear our product(s) each day?
 Hours per day:
How often do you wear our product(s) each week?
 Times per week:
How much overall reduction do you feel you received?
  0%       20%      40%      60%      80%      100%   
Amount of reduction
Did you have infections of your limb prior to using our product(s)?
Yes     No
If so, have you experienced a decrease in the frequency or severity of the infections?
Details:
Did you have a hardness of the skin of the affected limb?
Yes     No
If so, did this improve with use of our product(s)?
Details:
How did you hear about our product(s)?
Are you currently using any other treatment besides our product(s)?
(may choose more than one)

Bandaging     Pumps     Massage     Exercise     Garments
Other (Explain):

What treatment modalities have you used in the past?
(may choose more than one)

Bandaging     Pumps     Massage     Exercise     Garments
Other (Explain):

Are there any specific features you believe would improve the comfort or the application of our product(s) or serve your needs better?

Would you or have you recommended the use of our product(s) to others as a treatment option for lymphedema?
Yes     No

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:

(Optional)

Name:
E-mail:




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