Name
D.O.B. (mm/dd/yyyy)
Lymphedema Assessment Form for
Head and Neck
RELEVANT MEDICAL HISTORY
RELEVANT MEDICAL HISTORY
Arterial Disease
Venous Disease Heart Condition
Kidney Disease Thyroid Disorder
Respiratory Disease
Details:
Details: Allergies
GI/Digestive Issues
Dx/Imaging
Infections
Medications
Edema Treatment
Other
Note any sensitivities including fabrics, tapes/adhesivies
Note any constipation, diarrhea, IBS, Colitis, Crohn's, etc Details:
Note any hx trauma incl: surgeries; vein harvesting; vein stripping; vein injection; laser to veins, hernia repair, etc
Type and details, dates:
List medications, what each is taken for Details:
Note any US, MRI, lymphoscintigraphy, CT Scans, ICG-L, MRL, other diagnostic imaging, dates, findings)
#
Details:
MLD/CDT Bandaging
Garment(s)
Exercises
Skincare
Hyfrecation Cautery
Lymphedema Assessment Form for Head and Neck
ASSESSMENT
Note location(s), characteristics; use DIAGRAM, next page, as needed:
Note location(s), onset, quality:
o Pulses Palpable
Neuropathy o
Note location(s), onset, quality - use DIAGRAM, next page, as needed:
Swelling o
Swelling Stage
Pitting o Moderate/Severe o Severe
o o None Mild Moderate
Stemmer Sign Negative o Positive
Posture Fair o Poor o Good Note findings:
Head and Neck Function o Voice Changes
Difficulty Swallowing Difficulty Breathing Difficulty Hearing
Lymphorrhea
Skin and Nails Clear Fibrosis Hyperkeratosis Papillomas
Inflammation Signs
Infection Signs
Blood Clot Signs
Lipedema Signs
Wounds
Goal of Wound Mgmt
Difficulty w Dental Hygiene Stoma Difficulty Mastication Difficulty Coughing o Difficulty Sleeping Headache Dry Mouth Difficulty Communicating Difficulty w/Neck ROM
ASSESSMENT
Lobule(s) Fungal Issues Redness Swelling Spreading Pain, Local Feet spared Wet Maintenance Chylous Rash Warts Intertrigo Vesicles Heat Pain Fever w/Movement Symmetry Dry Healable
Note location(s), measurement, stage of healing
CONTINUED
Note location, severity, Hx
Note any related findings, re: colour, temperature, texture of the skin of the affected area(s) Active Management
Note location(s) and loss of function, skin movement or lack of Note Wound Care specialist/contact
Discolouration Non-Healable By: Sudden increase in swelling
Note any known cause/contributing factors, e g , arterial, venous, nutrition, co-morbidities, shear, trauma
Note wound care protocol in place, dressing type(s), etc
Physical Mobility:
Activities of Daily Living
NOTES
Note findings re: range of motion, posture, gait, balance, time spent sitting or standing
Notefindings,re:transfers,walking,breathing,dressing
CLIENT IDENTIFICATION
ASSESSMENT DIAGRAM
Legend: Edema Fibrosis Wounds Radiation Trauma/Surgery NOTES
NOTES
CONDITIONS ASSOCIATED WITH LYMPHEDEMA
(For information purposes only - not intended as diagnosis. Consult with MD if/as indicated).
Lymphedema Distichiasis Syndrome
Emberger Syndrome
Noonan Syndrome
Turner’s Syndrome
(double row of eyelashes, varicose veins, possibly heart condition)
(Lower limb lymphedema, genital lymphedema, lots of warts [even in non-lymphedematous areas], at risk to develop leukemia)
(leg swelling, atypical facial features, often chylous genital lymphedema)
(webbed neck, skin folds alongside neck to shoulders, leg swelling)
Prader-Willi Syndrome
Klippel Trenaunay Syndrome
Milroy/Nonne-Milroy
Meige
(onset at puberty)
Yellow Nail Syndrome
(muscular hypo tension, developmental disabilities, leg swelling) (overgrowth of the bones, muscle, and adipose tissue; nevus) venous and lymphatic anomalies) (onset at birth)
Anogenital Granulomatosis
(fungus under nail, brownish-yellow discolouration, pleural effusion) (fissures, genttal and lower extremity lymphedema, ulcers)
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