Lymph Node Swelling Evaluation Form
Please complete this form to help assess your lymph node swelling and related symptoms.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Evaluation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Location of Swelling
*
Please Select
Neck
Armpit
Groin
Other
How long have you noticed the swelling?
*
Please Select
Less than 1 week
1-2 weeks
2-4 weeks
More than 1 month
Please rate the severity of the swelling
*
Mild
1
2
3
4
Severe
5
1 is Mild, 5 is Severe
Associated Symptoms (select all that apply)
Fever
Night sweats
Unintentional weight loss
Fatigue
Pain or tenderness
None of the above
Other
Relevant Medical History
Rows
Yes
No
Recent infection
1
2
History of cancer
3
4
Autoimmune disease
5
6
Recent travel
7
8
Animal exposure
9
10
Please provide any additional information or concerns about your lymph node swelling
Submit Evaluation
Should be Empty: