Name (last, first, MI)
D.O.B. (mm/dd/yyyy) Height
Diabetes
Arterial Disease
Venous Disease
Heart Condition
Kidney Disease Thyroid Disorder
Respiratory Disease o
Allergies
GI/Digestive Issues
RELEVANT MEDICAL HISTORY
RELEVANT MEDICAL HISTORY
Details:
Details:
Details:
Note any sensitivities including fabrics, tapes/adhesivies
Note any constipation, diarrhea, IBS, Colitis, Crohn's, etc
Note any hx trauma incl: surgeries; vein harvesting; vein stripping; vein injection; laser to veins, hernia repair, etc
Type and details, dates:
Dx/Imaging
Note any US, MRI, lymphoscintigraphy, CT Scans, ICG-L, MRL, other diagnostic imaging, dates, findings)
Infections
List medications, what each is taken for
Medications
Family History of
Edema Treatment MLD/CDT Bandaging
Garment(s)
Procedure Lymph Node Dissection Metastasis
Antibiotic regimen: # Nodes Recurrence
Hyfrecation Cautery
Suction-Assisted Lipectomy Medication Lymphovenous anastomosis
Other health history
Lymphedema Assessment Form for Lower Extremity, Genital and Trunk
Note location(s), characteristics; use DIAGRAM, next page, as needed:
Note location(s), onset, quality:
Neuropathy o
Swelling Stage
NOTES
Lymphorrhea
o Pulses Palpable
Note location(s), onset, quality - use DIAGRAM, next page, as needed:
ASSESSMENT CONTINUED
Note location, severity, Hx
Inflammation Signs
Infection Signs
Blood Clot Signs
Lipedema Signs
Wounds
Goal of Wound Mgmt
Skin and Nails Clear Fibrosis Hyperkeratosis Papillomas 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
Note any related findings, re: colour, temperature, texture of the skin of the affected area(s)
Note location(s) and loss of function, skin movement or lack of
Active Management
Discolouration Non-Healable By: Sudden increase in swelling
Note Wound Care specialist/contact
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
Lymphedema Assessment Form for Lower Extremity, Genital and Trunk
CLIENT IDENTIFICATION
ASSESSMENT DIAGRAM
Legend: Edema Fibrosis Wounds Radiation Trauma/Surgery NOTES
Lymphedema Assessment Form for Lower Extremity, Genital and Trunk
CLIENT IDENTIFICATION
SUMMARY
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)
Prader-Willi Syndrome
Klippel Trenaunay Syndrome
Milroy/Nonne-Milroy
Meige
(webbed neck, skin folds alongside neck to shoulders, leg swelling) (muscular hypo tension, developmental disabilities, leg swelling) (overgrowth of the bones, muscle, and adipose tissue; nevus) venous and lymphatic anomalies) (onset at birth)
(onset at puberty)
Yellow Nail Syndrome
Anogenital Granulomatosis
(fungus under nail, brownish-yellow discolouration, pleural effusion) (fissures, genttal and lower extremity lymphedema, ulcers)
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