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Oedema Assessment Form

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Name *

First

Last

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Phone

Birthday

GP's Name *

GP's Phone

GP Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Name of Oncologist *

Oncologist's Phone

Oncologist's Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Name of Surgical Consultant *

Consultant's Phone

Surgical Consultant's Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

May the therapist contact your GP/Consultants if appropriate? *

Yes
No

Therapist may require a clearance letter from the medical team prior to treatment.

Current Medical Diagnosis

Referred by:

Referral Letter *

Yes
No

LIFESTYLE

Occupation:

Hobbies:

Exercise:

Smoker: *

Yes
No

Do you have someone to help you day-to-day? *

Yes
No

DRUG HISTORY

Antibiotics *

Yes
No

Date of last Antibiotics

Do you suffer from any of the following:

Active TB in last 6 months *

Yes
No

Cardiovascular Disease *

Yes
No

Congestive Cardiac Failure *

Yes
No

Cellulitis *

Yes
No

Chronic Skin Conditions *

Yes
No

Diabetes *

Yes
No

D.V.T. in last 6 months *

Yes
No

Hypertension *

Yes
No

Kidney Disease *

Yes
No

Lung Disease *

Yes
No

Liver Disease *

Yes
No

Musculoskeletal *

Yes
No

Neurological Disease *

Yes
No

Ulcers *

Yes
No

Family History *

Yes
No

Other *

Yes
No

If you have answered 'YES' to any of the above questions, please explain further:

CANCER HISTORY (with dates if applicable)

Primary:

Metastasis:

Treatment received:

Diagnostic Examinations to Date:

Planned/Current treatment:

Cancer Status:

Remission
Active
Palliative

Comments:

PRESENTING PROBLEM (Lymphoedema)

Has Lymphoedema Been Diagnosed? *

Yes
No

Types *

Primary LE
Secondary LE
Venous
Undiagnosed
Not Investigated
Other

Date of onset:

Trigger:

Does it reduce overnight? *

Yes
No

Treatment Received To Date:

Compression Bandaging *

Yes
No

MLD *

Yes
No

Medication *

Yes
No

Exercises *

Yes
No

Compression Garment *

Yes
No

Currently Worn *

Always
Sometimes
Never

Brand Type, CC

OEDEMA ASSESSMENT

Upper Arm

Left Side
Right Side

Forearm

Left Side
Right Side

Hand

Left Side
Right Side

Fingers

Left Side
Right Side

Upper Leg

Left Side
Right Side

Lower Leg

Left Side
Right Side

Foot

Left Side
Right Side

Toes

Left Side
Right Side

Face

Left Side
Right Side

Neck

Left Side
Right Side

Breast

Left Side
Right Side

Abdomen

Left Side
Right Side

Trunk

Left Side
Right Side

Genitals

Left Side
Right Side

SKIN ASSESSMENT

Dry Skin

Fungal Infection

Lymphangioma

Papillomatosis

Inflammation

Hyperkeratosis

Rash

Condition of nails

Stemmer Sign: *

Positive
Negative

PAIN ASSESSMENT

Pain Score *

0 = No Pain
1 = Mild
2 = Moderate
3 = Severe
4 = Very Severe
5 = Intolerable

Nature of Pain *

Heaviness
Tightness
Dull Ache
Sharp Pain
Pins & Needles
Other

Is the pain *

Constant
Intermittent

What affects the pain:

PATIENT CONSENT

I have been informed of the physical nature of the assessment required and possible treatment strategies and give my consent:

I give my consent to photographs being taken: (For clinic purposes) *

Yes
No

Name *

First

Last

Date *

Message

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About
Treatments
Lipoedema
Lymphoedema
Nutrition
Vouchers