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Lymphatic Care Questionnaire | Level Up Rehabilitation Services
Level Up Rehabilitation Services

Lymphatic Care Questionnaire

A complete new-patient questionnaire for lipedema, lymphedema, and chronic swelling. Map your symptoms, complete the Lymphedema Life Impact Scale, and send it straight to Dr. Grace.

Patient InformationStep 1

Patient Information

Let's start with your details. Fields marked * are required.

Emergency Contact
Referring Provider
Additional Details

Chief Complaint & History

Tell us what brings you in and how your symptoms behave.

Diagnosis / Reason for Visit
Your Symptoms
NoneModerateSevere

Pain Diagram & Rating

Show us where it hurts and how strong it is. This replaces a paper pain chart.

Mark Your Symptoms

Pick a symptom type, then tap the body where you feel it. Tap a mark again to remove it. Use both the front and back figures.

Front
Back
Rate Your Pain (past 24 hours)
No painModerateWorst imaginable
No painModerateWorst imaginable
No painModerateWorst imaginable

Lipedema Assessment

Complete this section if lipedema is known or suspected.

Lymphedema Assessment

Complete this section if lymphedema is known or suspected.

Chronic Inflammation & Immune History

This helps Dr. Grace understand the bigger picture.

Medical & Surgical History

Anything relevant to your care.

Lifestyle & Functional Status

How your condition affects daily living.

No impactModerateSevere

Prior Treatments & Goals for Care

What you have tried, and what success looks like for you.

Lymphedema Life Impact Scale

A short, scored questionnaire (version 2) that measures how lymphedema affects daily life. It is scored automatically so your therapist can track changes over time.

Lymphedema Life Impact Scale
Rate each item based on how your lymphedema has affected you in the past week.If swelling and symptoms are the same in both limbs, rate them the same; otherwise rate only the worst limb.Choose the number that best describes your symptom level: 0 = no impact, 4 = most severe.If you do not have swelling or lymphedema, let your therapist know; this section may not apply to you.
About this scale

Lymphedema Life Impact Scale, version 2. © 2018 Oncology Section, APTA. Administered clinically by Level Up Rehabilitation Services. Please confirm digital-use permission with the publisher before this form goes live.

Lymphedema: Physical Concerns

Items 1–6. Rate each over the past week.

0 = no pain4 = severe pain
0 = no heaviness4 = extremely heavy
0 = no tightness4 = extremely tight
0 = normal size4 = extremely large
0 = normal movement4 = movement extremely limited
0 = normal strength4 = extremely weak

Lymphedema: Psychosocial Concerns

Items 7–12. There are no right or wrong answers.

0 = not at all4 = completely
0 = no interference4 = interferes completely
0 = no interference4 = interferes completely
0 = never4 = constantly
0 = not at all4 = completely
0 = good understanding4 = no understanding

Lymphedema: Functional Concerns

Items 13–17. How lymphedema affects daily function.

0 = no interference4 = interferes completely
0 = no interference4 = interferes completely
0 = no interference4 = interferes completely
0 = fits normally4 = unable to wear
0 = no interference4 = interferes completely

Lymphedema: Infection Occurrence

Item 18. This is counted separately from the score.

Infection history is recorded separately and is not included in the total impairment score, following the scale’s original scoring method.

Cancellation & No-Show Policy

Please review and acknowledge.

SituationFee / Consequence
No-ShowFull session fee charged to card on file
Cancellation < 24 hours$50.00 late cancellation fee
Cancellation ≥ 24 hoursNo charge, thank you for the courtesy

No-show: failing to attend with no prior notice results in the full visit fee charged to the card on file. A written appeal may be submitted within 7 days for documented medical emergencies.

Late cancellation (under 24 hours): incurs a $50.00 fee regardless of reason, except documented emergencies reviewed case-by-case. This fee is not covered by insurance and is your direct responsibility. To avoid it, cancel at least 24 hours ahead.

To cancel or reschedule: online at levelupptdoc.com, phone (703) 637-8252, or fax (571) 617-0044.

By scheduling, you authorize Level Up Rehabilitation Services, LLC to charge applicable fees to your payment method on file. Fees are non-refundable except at management’s discretion.

Consent & Authorization

Please review and acknowledge below.

By submitting this form, I confirm that:

  • The information on this form is accurate and complete to the best of my knowledge.
  • I consent to evaluation and treatment by Dr. Grace Villaver, DPT, CLT, and the staff of Level Up Rehabilitation Services, LLC.
  • I understand that treatment for lipedema, lymphedema, and/or chronic inflammation may require multiple sessions and an active home program.
  • I authorize coordination of care and communication with my referring or treating providers as needed.
  • I have been given the opportunity to ask questions and understand I may withdraw consent at any time.

Your Results

Here is your scored Lymphedema Life Impact Scale and a summary of your responses. Review it, then submit. Your questionnaire goes directly to Dr. Grace.

Thank you. Your questionnaire is complete.

Your questionnaire is complete and on its way to Dr. Grace’s office.

Your privacy, protected

For your privacy, your copy is shown here only once and is not saved on any website. Please download it now and keep it somewhere safe. The file is password protected: open it with your date of birth as 8 digits in year, month, day order (for example 19900215 means 15 February 1990). A copy has also been sent securely to Dr. Grace’s office.

Call (703) 637-8252

The download is a single secure file. Open it in any web browser and enter your date of birth.

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