Your Practice — Lymphoedema Management Consultation

Personal Details

Tell us a little about yourself.

First Name

Surname

Address

Phone

Date of Birth You can type your date of birth (dd/mm/yyyy) or choose it from the calendar.

GP name & surgery

Emergency contact name

Emergency contact phone

Relationship to you

Diagnosis and clinical team

Have you been diagnosed with lymphoedema or chronic oedema?

Yes No

Type or cause, if known

Primary lymphoedema

Secondary to cancer treatment

Secondary to surgery or trauma

Lipoedema with lymphatic involvement

Other or not known

Lymphoedema service, GP, consultant or other clinical team details

Current clinical care plan and any treatment restrictions

Current condition

Areas affected and which side(s)

When did the swelling or symptoms begin?

Current swelling, heaviness, tightness, discomfort, reduced movement or other symptoms

How symptoms change during the day and what improves or worsens them

Impact on movement, work, sleep and daily activities

Current and previous management

Compression garments or bandaging: type, strength, fit and wearing routine

MLD, SLD or other lymphatic drainage currently used

Exercise, movement and breathing programme

Skin-care routine and any difficulties

Response to previous treatment and any adverse effects

Clinical and safety screening — please tick any that currently apply:

Current or suspected cellulitis, infection, fever or acute illness

Known or suspected blood clot / DVT

Sudden, unexplained or rapidly increasing swelling

Heart failure or significant heart condition

Kidney disease or impaired kidney function

Active cancer or current cancer treatment

Open wound, leaking skin, ulcer or pressure damage

Cellulitis and skin history

Previous cellulitis episodes, dates and treatment

Redness, heat, dryness, cracking, fungal infection, wounds or leakage

Allergies or sensitivities to garments, dressings or skin products

Management goals

What would you most like help with?

Any support or techniques you would like discussed with the practitioner

Lymphoedema management consent

Lymphoedema is a long-term condition. This form records information for practitioner assessment and ongoing management; it does not provide a diagnosis or replace care from a lymphoedema service, GP or hospital team.

Data Protection (UK GDPR)

I hereby declare that the details are true and correct to the best of my knowledge and I undertake to inform you of any changes immediately. I have read and acknowledged the Privacy/GDPR policy. Thank you kindly for visiting us today and completing this form. Hope to see you again soon.

Client Signature

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Date

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Lymphoedema Management Consultation

Personal Details

Diagnosis and clinical team

Current condition

Current and previous management

Clinical and safety screening — please tick any that currently apply:

Cellulitis and skin history

Management goals

Lymphoedema management consent

Data Protection (UK GDPR)

Client Signature

Age Restriction

Additional Information