L↑
Level Up Rehabilitation Services
Dr. Grace Villaver, DPT, CLT · levelupptdoc.com
New Patient Intake
Step 1 of 6
Patient Demographics
Basic patient information and reason for visit.
Personal Information
Referring Provider & Insurance
Primary Complaint & Goals
Leg/arm swelling
Pain / heaviness
Skin changes
Post-surgical edema
Fatigue
Autoimmune flare
Garment management
Other
Step 2 of 6
Lipedema Assessment
Foldi staging and symptom characterization.
Note: Lipedema presents as bilateral, symmetrical fat accumulation. Stemmer sign is negative in pure lipedema.
Lipedema Diagnosis Status
Yes — confirmed diagnosis
Suspected — not yet diagnosed
Ruled out
Unknown
Foldi Stage Classification
Stage I
Smooth Skin Surface
Soft, spongy tissue. Normal skin surface. Swelling increases throughout the day.
Stage II
Uneven Skin, Nodules
Mattress-like skin. Palpable nodules. Lipodermatosclerosis begins.
Stage III
Large Lobules
Large overhanging tissue folds. Significant deformity. Mobility affected.
Stage IV
Lipolymphedema
Lipedema + secondary lymphedema. Positive Stemmer sign. Full CDT required.
Symptom Severity
Pain (0-10)
5
Heaviness (0-10)
5
Tenderness (0-10)
5
Step 3 of 6
Lymphedema History
ISL staging, etiology, and CDT history.
Lymphedema Status
Confirmed — primary
Confirmed — secondary
Suspected
Not present
Breast cancer / mastectomy
Pelvic / gynecologic cancer
Radiation therapy
Lymph node dissection
Trauma / infection
Chronic venous insufficiency
Unknown
ISL Stage
Stage 0
Latent / Subclinical
No visible swelling. Transport capacity impaired.
Stage I
Reversible Edema
Pitting edema. Reduces with elevation. No fibrosis.
Stage II
Irreversible Edema
Non-pitting. Fibrotic changes. Positive Stemmer sign.
Stage III
Elephantiasis
Severe skin changes. Major volume. Significant impairment.
Contraindication Screening
Step 4 of 6
Autoimmune & Inflammation Markers
Autoimmune conditions, inflammatory symptoms, and MLD candidacy.
Autoimmune Diagnoses
✓
Rheumatoid Arthritis
Joint effusion, morning stiffness
✓
Lupus (SLE)
Peripheral edema, serositis
✓
Multiple Sclerosis
Immobility-related lymphedema
✓
Hashimoto’s Thyroiditis
Myxedema, fatigue, heaviness
✓
Sjogren’s Syndrome
Facial / parotid swelling
✓
Post-COVID Syndrome
Lymphatic dysregulation, POTS
✓
Psoriatic Arthritis
Joint inflammation, skin plaques
✓
Inflammatory Bowel
Crohn’s / UC manifestations
✓
Other / Unknown
Undifferentiated inflammatory
Inflammatory Symptom Profile
Fatigue (0-10)
5
Joint Swelling (0-10)
5
Morning Stiffness (0-10)
5
Generalized Edema (0-10)
5
Step 5 of 6
Garment Compliance Tracker
Current compression garment use, compliance, and fit status.
Current Compression Garments
Garment
Has One?
Compliance
Hrs/Day
Compression StockingsDaytime lower extremity
Yes
No
Nighttime CompressionBandaging or low-stretch garment
Yes
No
Arm SleeveUnilateral or bilateral
Yes
No
Garment Fit & Barriers
Difficult to put on/remove
Uncomfortable / tight
Too hot
Cosmetic concerns
Cost / insurance coverage
Poor fit
No barriers — good compliance
Step 6 of 6
Intake Summary
Review before submitting to Dr. Villaver’s intake queue.
Clinician Notes