Please Note:  The purpose of this form is to gather information to be presented to a Physician to be looked over
for research.  This is to try and help physicians find better treatments for our loved ones.  Your information will be
kept completely confidential and only used for reasons stated above.  If you have questions email us at  
admin@littleleakers.com .  
Thank you so much for taking the time to answer the above questions. And for participating in helping our
voices to be heard for the sake of our loved ones.  Also for giving us the strength to make a difference.  
Please note that your information will only go to a Physician for purposes of research.  We have had many
request for this information.  We will not release this information other than the above stated.  If you have
questions please feel free to contact us.  Again thank-you for your help and support.  
Information Form For Lymphangiectasia
Patient Name:
Patients Gender:
Male
Female
Date of Birth:
Is the patient with IL the eldest child?:
Yes
No
Date Diagnosed:
Diagnoses:
If not where does he/she fall:
(example: 1st child, 2nd child, etc.)
What were the initial symptoms:
When did you first notice any symptoms:
Medicines Currently Taking:
Treatments Currently Receiving:
Type of Diet:  (if any)
Tests that have been performed: (Please give dates if possible)
Where is the Patient being Treated: (Hospital, Medical Facility)
If so please list any other condition:
Does the patient receive any nutritional assistance:  (dietician/nutritionist or Tpn, tube feed, etc.)
Were there any complications during the pregnancy of the child with IL:
Were any medications given to the Mother before or during labor:
Natural
Was the birth:
Caesarian
Any studies on IL that you have come across:
Any additional information that you have learned on IL that you are willing to share:
Any comments as to what treatments have been helpful and have not been:
Any good low fat recipes:
Is there any information that you would like to see on our web site?
Little Leakers