Please bring completed form to your appointment or fax prior to your appointment to
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1 Courage Kenny Rehabilitation Institute Edema/Lymphedema Clinic Please bring completed form to your appointment or fax prior to your appointment to Section One: Background Information Name: Date of Birth: Reason for appointment: Referred by: Primary Care Provider: Name, Address, & Fax: Specialty Care Providers: Names, Full Addresses, & Faxes (Please attach separate sheet if needed): Section Two: Swelling & Edema Swelling history: Please list locations of swelling: Please list approximate date of onset: Has the swelling gotten better, worse, or stayed the same? What makes it get better or worse? Page 1 of 5
2 Have you ever been prescribed a medication for edema? Length of use. Did it work? Have you ever worn edema garments or bandages? Dates of use. Length of use. Types of garments. Have you ever received Lymphedema Therapy for the edema from a PT or OT lymphedema therapist? Please provide names and addresses: Have you ever had wounds? Please provide dates. Please provide treatment that was administered: Have you ever had cellulitis or infection related to edema? Please list approximate dates. Please include treatment including hospitalizations, antibiotics, topical preparations, creams and lotions. Have you ever had surgery or procedures performed for edema, veins, weight loss, or plastic surgical procedures? Please provide the date and result of each procedure. What has been your highest adult weight and when were you at this weight? What is your lowest adult weight and when were you at this weight? Have you ever had a blood clot in your arm or leg? Please list all occurrences and treatments. Page 2 of 5
3 Section Three: PsychoSocial History Family History: Please list all family members with a history of swelling, what problem they each had, along with their relationship to you: Marital Status: Married Single Widowed Life Partner Employment Status: Employed Unemployed Retired What is/was your occupation? Daily Activities: Please list any activities that are performed on a daily basis (i.e. type of work, hobby, home chores, home making, etc.): Social History: How has your current situation affected your daily activities, social relationships, sexual relationships, sleep, energy, mood and pain? Physical Activity History: Do you or have you ever exercised regularly? Describe. What would you like to be able to do for exercise? What is the one activity you cannot do now that you most wish you could do? Page 3 of 5
4 Section Four: Medical History Past Medical History: Please list all surgeries, hospitalizations, and any other medical conditions. Please include dates for each. Have you ever had any of the following? If yes, please describe. Use additional sheet or add an attachment if necessary: I. Fevers, Fatigue, Weakness: II. Infections or immune system problems: III. Ear, Eyes, nose, throat, sinus problems: IV. Cardiovascular (heart disease, hypertension, heart surgery, vein or artery disorder or surgery, coagulation disorder or therapy): V. Lung (asthma, emphysema, cancer, lung surgery, etc.): VI. Gastrointestinal including stomach, intestinal, bowel: VII. Kidney,Bladder,Urinary: VIII. Endocrine including diabetes, thyroid: IX. Skin diseases or skin, history of poisonous bite, rash: X. Muscular or joint problem, trauma, injury or surgery: XI. Pain or limited range of motion: XII. Neurologic problem: neuropathy, stroke, migraines, brain tumor: XIII. Difficulty walking or balancing: XIV. Difficulty with hands or dexterity: XV. Difficulty with speech or swallowing: XVI. Mental Health (depression, anxiety, chemical abuse, memory problems, hospitalizations for mental healthplease include all dates): Page 4 of 5
5 Section Five: Meds/allergies Medications: List all medications you take regularly or irregularly. Include over the counter medications, vitamins, supplements. Please include generic name and dosages. Attach a separate sheet if necessary: Allergies: Please list all allergies to medications and your reactions to them. How do you learn best? Discussion Reading Demonstration Visual Classroom Individual Instruction Other Signature (of Patient or person filling out the form) Name of person filling out this form if not the patient Relationship to patient Date: Time: Page 5 of 5
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