LYMPHEDEMA PATIENT HISTORY
PATIENT’S NAME: _______________________________________________ DATE: _____________________
SUBJECTIVE:

Please CIRCLE the picture (to the right) with all the areas of swelling currently involved:

Do you have pain that you relate directly to the swelling? YES NO
If so, please mark (XXXX) on the picture to the right.

List what aggravates the swelling or other symptoms:
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Have you done anything that has helped relieve the swelling or other symptoms?
Please list:___________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

What activities have become difficult or unable to perform as a result of swelling?
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Please describe your lifestyle. Check one:
Sedentary (no routine exercise)
Minimally active (exercise once per week)
Moderately active (exercise 3 times per week) Very active (exercise more than 3 times per week)
Occupation: _________________________________________________
HISTORY:
1.
2.
3.
4.
5.
6.
7.
8.
How long have you had lymphedema? ______________________________________________________
Where did you first notice the swelling? _____________________________________________________
Please describe any background condition that might have caused the lymphedema, e.g. injury, surgery, or
cancer. Specify type (breast, prostate, uterine, melanoma, other):__________________________________
______________________________________________________________________________________
Please list any relevant surgeries and dates: ___________________________________________________
______________________________________________________________________________________
Have you had any infections related to lymphedema?:
YES NO
If yes, list dates and treatment: _____________________________________________________________
______________________________________________________________________________________
Have you had chemotherapy?
YES NO
If yes, list dates and drugs of last administration: ______________________________________________
______________________________________________________________________________________
Have you had radiation treatment? YES NO
If yes, list dates and sites: _________________________________________________________________
______________________________________________________________________________________
Have you had special tests (doppler, lymph angioscintigraphy)? YES NO
If yes, list type of tests: ___________________________________________________________________
______________________________________________________________________________________
9.
Please CIRCLE any of the following you may have at this time:
Malignant Disease
10.
Cardiac Edema
Infection
Open Wounds
Thrombosis
Inflammation
Have you had any of the following? (Please indicate the dates)
Anemia__/__/__
Phlebitis__/__/__
Cancer__/__/__
Stroke__/__/__
Diabetes__/__/__
Allergies__/__/__
Rheumatic Fever__/__/__
Back Problems__/__/__ Burns__/__/__
Glaucoma__/__/__
Migraine__/__/__
Asthma__/__/__
Bleeding Disorder__/__/__
Hepatitis__/__/__
Lung Disease__/__/__
Varicose Veins__/__/__
Arthritis__/__/__
Blood Clots__/__/__
Leg Ulcers__/__/__
Heart Problems__/__/__ Scarlet Fever__/__/__
Dizziness__/__/__
Broken Bones__/__/__
Epilepsy__/__/__
Kidney Disease__/__/__
Muscle/Joint Weakness__/__/__
Blood Circulatory Problems
11.
Do you have any other medical condition that has not been previously identified? (Please specify):
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
12.
Please list current medications: ____________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
13.
Previous Lymphedema Treatment:
14.
a.
Have you had previous lymphedema therapy?
YES NO
If so, specify dates and outcomes: ___________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
b.
Do you wear a compression garment (i.e. sleeve or stocking)? YES NO
If so, how often and how long? _____________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
c.
Have you ever used a pneumatic compression pump?
YES NO
If so, when and how often? ________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
d.
Do you:
e.
Please describe your current management? ____________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
1.
2.
3.
4.
5.
Use diuretics?
YES NO
Elevate the limb?
YES NO
Bandage the limb?
YES NO
Do your own bandages?
YES NO
Do you use or own any type of compression device such as a Reid Sleeve,
Legacy, CircAid?
YES NO
If yes, please specify: ______________________
How were you referred to our Lymphedema Program? __________________________________________
______________________________________________________________________________________