|
HPI (Lipedema)
|
|
|
Affected areas
• • •
|
|
|
History of Present Illness
• • •
|
Symptoms present for
|
|
How long has the patient been diagnosed
|
Therapeutic Lipedema Measures
• • •
|
|
Previous weight loss attempted
• • •
|
Previous Lipedema Surgery
• • •
|
|
Limitations:
|
BMI:
|
|
Where did you find us?
|
|
|
Who referred you?
|
|
|
Premera Criteria
|
Regence Criteria
|
|
Criteria
• • •
|
Criteria
• • •
|
|
Aetna Criteria
|
|
|
Criteria
• • •
|
Aetna Physical Exam findings
• • •
|
|
BCBSIL Criteria
|
Criteria
• • •
|
|
Kaiser Criteria
|
Criteria
• • •
|
|
HPI (Cosmetic)
|
|
|
Patient Problem
|
|
|
Patients Goals
|
|
|
Specific surgery pt is considering:
|
|
|
Previous Treatment
|
|
|
Please list at least one emergency contact
|
|
|
Emergency contact 1
|
Relationship
|
|
Phone number
|
|
