|
Lipodystrophy
|
|
|
Areas that are bothersome
• • •
|
Comments
|
|
Skin Quality of area
|
|
|
Breast Exam and History
|
|
|
Breast History
|
|
|
Bra Size
• • •
|
Bra Size Comments
|
|
Breast CA Family History (immediate)
|
|
|
Mammography (available)
|
Mammography Results
|
|
Breast Exam
|
|
|
Ptosis Grade
|
Base Width (cm)
|
|
SN-N Distance (cm)
|
Capsular Contracture Grade
|
|
Breast consistency
|
Tuberous Grade
|
|
Additional comments
|
|
|
Lipedema Physical Exam
|
|
|
Lipedema Physical Exam
|
|
|
Areas that are bothersome
• • •
|
symmetric fatty tissue
|
|
Arms
|
|
|
Lipedema in arms
|
Wrist Cuffing
|
|
Hands Normal/Abnormal
|
Comments
|
|
Legs
|
|
|
Lipedema in legs
|
Ankle Cuffing
|
|
Feet Normal/Abnormal
|
Stemmer's Sign
|
|
Comments
|
|
|
Thighs
|
|
|
Lipedema in thighs
|
Comments
|
|
Trunk
|
|
|
Lipedema in trunk
|
Saddlebag severity
|
|
Comments
|
|
|
Skin Quality of area
|
|
|
Don't fill out
|
|
|
Pitting Edema
|
|
|
Telangiectasias of affected areas
|
|
|
Hypothermia of affected areas
|
Bruising of affected areas
|
|
Scar Revision
|
|
|
Width
• • •
|
Length
• • •
|
|
Thickness
• • •
|
Pliability
• • •
|
|
Vascularization
• • •
|
Pigmentation
• • •
|
|
Is the scar fixed to underlined structure?
|
|
|
Face
|
|
|
Face
|
|
|
Areas that are bothersome
• • •
|
Comments
|
|
Skin quality
|
|
|
GYN
|
|
|
GYN
|
|
|
Areas that are bothersome
• • •
|
Comments
|
|
Skin excess
|
|
