Your Practice — Post-operative MLD 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

Surgical procedure

Procedure or operation

Date of surgery

Areas treated and relevant surgical details

Surgeon or treating clinic

Surgeon or clinic contact details

Post-operative instructions, restrictions or treatment protocol

Current recovery

Current swelling, bruising, discomfort or numbness

Current pain score (0 = no pain, 10 = worst pain) Please enter a number from 0 to 10

Are any surgical drains still in place?

Yes No

Are any incisions open, leaking or not fully healed?

Yes No

Compression garments currently prescribed or worn

Planned surgical follow-up appointments

Post-operative safety screening — please tick any that currently apply:

Fever, chills or feeling acutely unwell

Increasing redness, heat, discharge, odour or suspected infection

Severe or rapidly worsening pain or swelling

New breathlessness, chest pain, fainting or coughing blood

New one-sided calf or limb pain, heat, redness or swelling

Known or suspected seroma or haematoma

Unplanned medical review or hospital readmission since surgery

Medical history and medication

Help your therapist provide safe treatment.

Relevant medical conditions and previous operations

Current medication, including pain relief, antibiotics and anticoagulants

Allergies, adhesives or skin sensitivities

Post-operative MLD consent

Post-operative MLD does not replace surgical follow-up or urgent medical care. The practitioner may postpone treatment and ask you to contact your surgical team or another healthcare professional if recovery concerns are identified.

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

Please sign below.

Date

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Post-operative MLD Consultation

Personal Details

Surgical procedure

Current recovery

Post-operative safety screening — please tick any that currently apply:

Medical history and medication

Post-operative MLD consent

Data Protection (UK GDPR)

Client Signature

Age Restriction

Additional Information