Lymphedema Intake

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Personal Info

First Name

Last Name

Date of Birth (MM/DD/YYYY)

Gender

Occupation

Contact Info

Mobile Phone

Home Phone

Work Phone

Source of Referral

Address

City

Country

Province / State

Postal / Zip Code

Emergency Contact

Emergency Phone

Relationship

Doctor

Doctor's Name

Doctor's Phone

Doctor's Address

Manual Lymphatic Drainage cannot be performed on people with the conditions below. Please check if any of these apply:

Decompensated Cardiac Insufficiency

Untreated Congestive Heart Failure (CHF-Cardiac Edema)

Untreated Cancer

Acute Inflammation caused by pathogenic germs (bacteria, fungi, viruses).

Acute Renal Failure

Acute Deep Venous Thrombosis (DVT/blood clots)

Fever - Acute Cold/Flu

Not Applicable

Health History

Have you been diagnosed with Lymphedema? If Yes, by whom:

How long have you had swelling/Lymphedema?

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Was there a trigger event which caused the swelling/Lymphedema?

Please describe briefly how and why your swelling/Lymphedema developed:

Have you had surgery? If so, please list surgeries and dates.

Have you had any lymph nodes removed? If yes, how many? Please specify location.

Have you ever received radiation therapy for cancer?

Yes

If Yes, list the area of radiation and dates here:

Have you had Chemotherapy? If yes, how long ago?

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Have you had any infections (Cellulitis)? If yes, when was the last occurence?

Is there a family history of Lymphedema? If yes, please explain.

Do you have pain? If yes, please explain.

Any loss of function or mobility? If yes, please explain.

What is your current living situation?

Private Home/Apartment (alone)

Nursing Home

Hospice Home with Spouse/Companion

Assisted Living

Other, please explain:

Do you have any other medical problems not listed above? If yes, please explain.

Are you allergic to:

Latex

Surgical Tape

Foam Products

Other

Are you taking any medication? If yes, please list and amounts taken.

At the time you are completing this, are you, or is there a chance you could be pregnant?

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Previous Treatments

Have you had previous treatment for swelling/Lymphedema? If Yes, check all that apply:

Manual Lymph Drainage (MLD)

Compression Pump

Compression Garments

Compression Bandaging

Flexitouch

Lymphedema Exercise

Low Level Laser

If yes, please explain your experience, success or lack of success.

Do you currently wear a compression garment? If so, which kind?

If Yes, how often do you wear it and how old is it?

Do you currently use compression at night? If yes, please explain.

Do you exercise regularly? If yes, please explain.

Are you familiar with the National Lymphedema Network?

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Are you familiar with the precautions (risk reduction practices) for Lymphedema?

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Are you a member of a breast cancer or Lymphedema support group? If yes, please explain:

Is there anything else you would like to tell me at this time?

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