First Name
*
Last Name
*
Email
*
Phone Number
*
Would you like to be contacted by Total Lipedema Care?
Yes
No
How did you learn about us?
Instagram
Friend
Google
Video
Did you hear about Total Lipedema Care or Dr. Jaime Schwartz?
Total Lipedema Care - @totallipedemacare
Dr. Jaime Schwartz - @drjaimeschwartz
Have you been officially diagnosed with Lipedema?
Yes
No
No, but I'm pretty sure I have it based on what I've researched
What stage of lipedema do you think you have?
One
Two
Three
Four
Unknown
How do you feel about your legs?
Hopeful
Hopeless
I love my legs
I'm worried for my legs
Do you think your lipedema is genetic?
Yes
No
Maybe
If yes, what is your ethnic background? (If Caucasian, please be as specific as possible, we have been seeing a link to German genetics)
Where do you have pain? (check all that apply)
Arms
Front of Legs
Back of legs
Calves
Stomach
No Pain
At what age did you start to develop signs of lipedema?
Please enter a number from
0
to
100
.
At what age did you have your first menstrual cycle?
Please enter a number from
0
to
100
.
Would you travel for lipedema surgery?
Yes
No
Maybe
Have you consulted with other doctors about lipedema?
Yes
No
If yes, what kind of doctor have you seen?
Have you have previous liposuction or lipedema treatment?
Yes
No
Yes, I'm happy with my results
Yes, but I'm unhappy with my results
If yes and you are unhappy with your results, please explain why:
Do you wear compression garments?
Yes
No
No, but I'd like to learn more about them
Do you use leg pumps?
Yes
No
No, but I'd like to learn more about them
If yes, what brand do you use?
What is your favorite way to exercise?
Cardio Machines
Running
Walking
Weightlifting
Yoga/Bare/Pilates
I don't exercise
Other
Have you had liposuction before?
Yes
No
Most lipedema patients need more than one surgery, would you be willing to have more than one surgery if needed?
Yes
No
Are you part of any lipedema facebook groups?
Yes
No
No, but I’d like to be part of a group
How has lipedema affected your life?
What type of food do you crave?
Sugar
Protein
Carbs/Breads/Pasta
Salt
Veggies
We've been researching fatigue and activity levels. Have you experienced depression?
Yes
No
If yes, did you experience depression at a younger age before lipedema became apparent?
Yes
No
Do you get brain fog and fatigue?
Yes
No
Do you have thyroid issues?
Yes
No
Is your blood work normal?
Yes
No
Do you consider yourself:
Overweight
A little overweight
Average
Underweight
Do you scar easily?
Yes
No
What is your favorite medium of learning about lipedema?
Google
YouTube
Instagram
Facebook
Other
What more would you like to see/read/listen to about lipedema and were would you like it posted?
Do you have any questions or thoughts or discoveries or a story you’d like to share?
Name
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