New Patient Registration Form

New Patient Registration and History
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
OK to send text reminders of appointment(s)?

YesNo
Secondary Number
Address:

Street Address

Street Address Line 2

CityState

Zip Code
Gender
In case of emergency...
Emergency Contact:

First NameLast Name
Emergency Çontact Number
Relationship
What is your current living situation?

Home or apartment (alone)Home or apartment with familyHome or apartment of friend/otherRetirement living facilityAssisted living facilityNursing homeHospiceOther
Insurance Information (tap the Plus button to add more than one insurance provider).
Height (ft/in)
Weight (pounds)
Are you taking any medications, currently?

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

EdemaPrimary Lymphedema (due to gentic condition)Secondary Lymphedema (due to cancer or cancer treatment)LipedemaTrauma/InjurySurgeryRemoval of Lymph NodesChemotherapyRadiationChronic Venous Insufficiency (CVI)Varicose VeinsDistended VeinsPoor Venous ReturnDeep Vein Thrombosis (blood clot)Congestive Heart Failure (CHF)Irregular heart beatPacemakerHigh blood pressureHeart diseaseChronic Obstructive Pulmonary Disease (COPD)AsthmaFrequent bronchitis or pneumoniaSleep apneaFrequent sinus or upper respiratory infectionsHyperthyroidismCrohn's DiseaseDiverticulitisDiabetes Type 1Diabetes Type 2Neuropathy (numbness, tingling or pain in fingers/hands or toes/feet)Stroke/TIALiver diseaseKidney diseaseMedication side effectsPregnancyLong-term standingTravelingHeat and/or humidityLatex allergyOther
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)

Right leg onlyLeft leg onlyBoth legsGenital areaAbdominal areaRight trunk/breast areaLeft trunk/breast areaBoth sides of trunk/breastsRight shoulderLeft shoulderBoth shouldersRight arm/handLeft arm/handBoth arms/handsHead/NeckOther
Other Current or Recent Symptoms:

CellulitisOther infection (specify type in the "other" box below)Weeping or seepingSmall open sores/ulcersLarge open sores/ulcersFalls (note how many in past year in Other)Hard spots or areas in the affected areaOther
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):

Walk within the home or workplaceWalk outside your home or workplaceWalk up/down a few stepsWalk up/down stairsGet up from or sit on a chair or bedSit comfortablySleepDress or undress (clothing & underwear)Manipulate fasteners (buttons, zippers, laces, etx)Put on or take off socks or shoesToileting (getting up/down, wiping, manipulating clothing, etc.)Wash or dry body (including feet, private areas)Wash or dry or style hairApply make up if desiredCut/trim and clean fingernails or toenailsPrepare or cook mealsPrepare snacksHouse chores (ie: picking up, wipe counters, wash dishes, gather/take out trash, etc.)Clean your home (ie: vacuum, sweep, mop, clean bathroom/ktichen, etc.)Outside chores (ie: mow, water, rake, etc.)Do laundryGet into or out of a vehicleDrive a vehicle or access public transportationGrocery shopPut away groceries or clothing or other itemsShop at other stores or the mallExercise at home or the gymWork (paid or volunteer)Type on a keboard or smart phoneTake care of others (such as spouse, children or grandchildren)Participate in social activities (ie: see/visit family, clubs, groups, meetings, entertainment, etc.)Participate in hobbies or other leisure activitiesOther
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?

NoManual Lymph MassageCompression (short-stretch) bandagingCompression garments for daytime useCompression garments for nighttime useLymphedema exerciseFlexiTouchOther compression pumpElevationOther
Do you have compression garments now?

NoYes
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:
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New Patient Registration and History