New Patient Registration Form

We know this seems like a long form to complete but the more information we have, the better we will be able help you. Also, by completing the form before your first visit, we will be able to do a treatment session in addition to the evaluation. Thank you!

Your Name

First NameLast Name

Date of Birth

MonthDayYear

Age:

E-mail

Your email will never be shared or sold.

Cell Number

Format: (000) 000-0000.

OK to send text reminders of appointment(s)?

Secondary Number

Format: (000) 000-0000.

Address:

Street Address

Street Address Line 2

CityState

Zip Code

Gender

In case of emergency...

Emergency Contact:

First NameLast Name

Emergency Çontact Number

Format: (000) 000-0000.

Relationship

What is your current living situation?

Insurance Information (tap the Plus button to add more than one insurance provider).

Height (ft/in)

Weight (pounds)

Are you taking any medications, currently?

List medications:

Medical Diagnosis, Conditions or Symptoms You May Have/Experience That May Contribute to Swelling (check all that apply):

Other reasons for swelling not listed above?

Was there any specific event that seems to seemed to trigger the swelling not noted above?

Chronic or frequent swelling in: (check all that apply)

Other Current or Recent Symptoms:

How long have you experienced the swelling noted above?

Other health diagnosis or conditions not listed above?

Has the swelling limited your ability to (check all that apply):

Lymphedema Life Impact Scale (LLIS) Version2

Note: If swelling and symptoms are the same in both limbs, rate them the same; otherwise, rate only the worst limb.

The amount of pain associated with lymphedema/swelling is:

	0	1	2	3	4

0 is No Pain, 4 is Severe Pain

The amount of limb heaviness associated with lymphedema/swelling is:

	0	1	2	3	4

0 is No Heaviness, 4 is Extremely Heavy

The amount of skin tightness associated with lymphedema/swelling is:

	0	1	2	3	4

0 is No Tightness, 4 is Extremely Tight

The size of the swollen limb(s) seems:

	0	1	2	3	4

0 is Normal Size, 4 is Extremely Large

The lymphedema/ swelling affects the movement of the swollen limb(s):

	0	1	2	3	4

0 is Normal Movement, 4 is Extremely Limited

The strength of the swollen limb(s) seems:

	0	1	2	3	4

0 is Normal Strength, 4 is Extremely Weak

Lymphedema affects body image (how I think I look):

	0	1	2	3	4

0 is Not at all, 4 is Completely

Lymphedema affects socializing with others:

	0	1	2	3	4

0 is No Interference, 4 is Interferes Completely

Lymphedema affects relationships with my family/friends:

	0	1	2	3	4

0 is No Interference, 4 is Interferes Completely

Lymphedema 'gets me (or the child) down' (i.e.: feelings of depression due to lymphedema):

	0	1	2	3	4

0 is Never, 4 is Constantly

I must rely on others for help due to lymphedema:

	0	1	2	3	4

0 is Not at all, 4 is Completely

I know what to do to manage the lymphedema:

	0	1	2	3	4

0 is Good Understanding, 4 is No Understanding

Lymphedema affects ability to perform self-care activities (i.e.: eating, drinking, hygiene):

	0	1	2	3	4

0 is No Interference, 4 is Interferes Completely

Lymphedema affects ability to perform home-related or education/work-related activities:

	0	1	2	3	4

0 is No Interference, 4 is Interferes Completely

Lymphedema affects performance of preferred leisure activities

	0	1	2	3	4

0 is No Interference, 4 is Interferes Completely

Lymphedema affects the proper fit of clothing/shoes:

	0	1	2	3	4

0 is Fits normally, 4 is Unable to Wear

Lymphedema affects my sleep:

	0	1	2	3	4

0 is No Interference, 4 is Interferes Completely

In the past year, I have become ill with an infection (or infections) in the swollen limb(s) requiring oral antibiotics or hospitalization:

	0	1	2	3	4

0 is None, 4 is 4 times or more

What do you hope to be able to achieve or do as a result of receiving therapy at Health Harmony Therapy?

Have you had previous treatment for the swelling?

Do you have compression garments now?

If yes, please bring the garments to your first visit.

Exercise

Please let us know if there is any other information you would like to share with us:

Date

MonthDayYear

By typing in your name below, you are verifying the information given in this form are truthful to the best of your knowledge:

New Patient Registration and History