LYMPHOEDEMA REFERRAL FORM

General Information

First name

Surname

Date of birth

Email Address

Home phone

Mobile phone

Home address

Communication Preference

Phone (call)Phone (SMS)EmailNo Preference

How did you find out about us?

Emergency Contact Information

Emergency contact

Phone

Emergency contact’s relationship to you

Work Information

Current work status

EmployedRetiredNot workingLight Duty

Occupation

Funding Information

Please choose the payment option most suited to you circumstances

NDISPrivate Payment MedicarePrivate Health FundDVA

Health Information

What are you seeing us about?

Do you have any current skin infections or a history of cellulitis?

Have you seen a medical doctor in the past for these conditions?

YesNo

Doctor

Date

Treatment

Specialist

Date

Treatment

Please list any medications you are currently taking

Medications

Dose

Please list any allergies (specifically skin based allergies e.g. latex or fabric)

Allergy

Severity

Please list any surgeries or medical procedures that you have undergone that are related to your lymphoedema (e.g. lumpectomy, mastectomy, lymph node removal, liposuction, radiation, chemotherapy)

Surgery

Date

Any other relevant medical history?

Do you consume alcohol?

NeverDailyOnce a weekOnce a monthOnce a year

Do you smoke?

YesNoI used to smoke

Do you use recreational drugs?

NoI have previously usedI currently use

Please attach a copy of the relevant referral form/letter (if applicable)

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Consent

I confirm that above information I have provided is true, complete and accurate. *

Signature

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Date

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