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EVALUATION FORM
MEDICAL HISTORY OF LYMPHOMEDA
Fill out the form below to help us understand your clinical picture
Name
Last name
Email
Date of birth
Have you been officially diagnosed with lymphedema?
NO
YES
Do you know the stage you are at?
NO
YES
If yes, indicate the stage and give a brief description of the symptoms. If you answered no, give a detailed description of your clinical picture. Also indicate if it is primary or secondary lymphedema
How long have you had lymphedema?
Today's Date
I declare that the information I have provided is valid and accurate
Submission
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