Lymphedema Therapy Assessment Form

Lymphedema Therapy Assessment Form — Form Fields

This healthcare template includes 14 fields. Assessment form for patients seeking lymphedema management and therapy services. Free to customize and use on ZenBuild.

• Patient Name (text, required)
• Date of Birth (text, required)
• Email (email, required)
• Phone Number (text, required)
• Referring Physician (text, required)
• Type of Lymphedema (dropdown selection, required) — options: Primary (hereditary), Secondary - Post-Surgical, Secondary - Post-Radiation, Secondary - Post-Infection, Lipedema, Unknown
• Affected Areas (checkboxes, required) — options: Right Arm, Left Arm, Right Leg, Left Leg, Trunk, Head/Neck, Genitals
• Duration of Swelling (dropdown selection, required) — options: Less Than 3 Months, 3-6 Months, 6-12 Months, 1-2 Years, 2-5 Years, 5+ Years
• History of Cancer Treatment (multiple choice, required) — options: Yes, No
• Cancer Type (if applicable) (text, optional)
• Currently Using Compression Garments (multiple choice, required) — options: Yes, No
• Current Symptoms (checkboxes, optional) — options: Heaviness, Tightness, Aching, Recurring Infections, Limited Range of Motion, Skin Changes, Numbness
• Treatment History (long text, optional)
• Insurance Provider (text, required)