formisoft
Lymphedema Therapy Patient Intake Form
Intake

Lymphedema Therapy Patient Intake Form

3 pages•18 fields•HIPAA-ready
Ready to useHIPAA compliantCustomize in minutes
Use this templateBrowse all templates

Form preview

formisoft.com/f/lymphedema-therapy-intake
Lymphedema Therapy Patient Intake Form

Lymphedema Therapy Patient Intake Form

Page 1 of 3

Patient Full Name
Jane Martinez
Date of Birth
03/15/1985
Primary Phone
(555) 867-5309
Email Address
jane.martinez@email.com
Referring Physician
Dr. Sarah Chen
Lymphedema Location
Cancer Treatment History
Enter details here...
Current Compression Garment Use
Option A
Option B
Option C
Frequency of Swelling Episodes
Select frequency...
Previous Infections (Cellulitis)
Enter details here...
Submit
Use this template

Sign up and start customizing in minutes.

This lymphedema therapy intake form is designed for certified lymphedema therapists (CLTs), physical therapy clinics specializing in lymphedema management, and oncology rehabilitation centers. The form systematically captures critical information about the onset, location, and severity of lymphedema, previous cancer treatments including radiation and lymph node removal, current compression therapy use, and skin integrity concerns that are essential for developing safe and effective complete decongestive therapy (CDT) protocols.

The template includes detailed sections for documenting swelling patterns, previous manual lymphatic drainage (MLD) experience, compression bandaging history, infection frequency, mobility limitations, and quality of life impacts. It helps therapists identify contraindications, assess stage of lymphedema, determine appropriate intervention strategies including MLD, compression bandaging, therapeutic exercise, and skin care education, while ensuring comprehensive documentation for insurance authorization and ongoing treatment planning.

What's included

  • Lymphedema onset and duration
  • Cancer treatment and surgical history
  • Lymph node removal documentation
  • Current compression therapy use
  • Swelling location and severity assessment
  • Cellulitis and infection history
  • Skin integrity evaluation
  • Mobility and functional limitations
  • Previous MLD or CDT experience
  • Quality of life impact assessment

Who uses this template

  • Certified Lymphedema Therapists
  • Oncology Rehabilitation Centers
  • Physical Therapy Clinics
  • Post-Mastectomy Clinics
  • Vascular Health Centers

All form fields

10 fields across 3 pages. Customize any field after signing up.

Patient Full NameText
Date of BirthDate
Primary PhonePhone
Email AddressEmail
Referring PhysicianText
Lymphedema LocationCheckbox
Cancer Treatment HistoryLong Text
Current Compression Garment UseMultiple Choice
Frequency of Swelling EpisodesDropdown
Previous Infections (Cellulitis)Long Text
8 min saved per patient98% patient satisfaction3x faster than paper

Start with this template

Sign up and start customizing the Lymphedema Therapy Patient Intake Form for your practice. Set up in minutes.

Use this templateBrowse all templates

Related templates

Full Name
Phone Number
Email Address
Referring Physician
Injury/Condition Description
Intake

Physical Therapy Intake Form

PT-specific intake with injury mechanism, pain assessment (VAS scale), functional limitations, range of motion goals, and treatment expectations. For physical therapy, sports medicine, and rehabilitation clinics.

2 pages•12 fields
Oncology Intake Form
Full Name
Date of Birth
Phone Number
Email Address
Cancer Diagnosis & Stage
Intake

Oncology Intake Form

Oncology-specific intake covering cancer diagnosis details, treatment history, chemotherapy regimens, symptom management, and psychosocial screening. For medical oncology, radiation oncology, and cancer centers.

4 pages•16 fields
Full Name
Date of Birth
Phone Number
Email Address
Vascular Disease History
Intake

Vascular Surgery Intake Form

Vascular surgery-specific intake covering arterial and venous disease history, claudication assessment, wound evaluation, prior vascular interventions, and cardiovascular risk factor documentation. For vascular surgeons and endovascular specialists.

3 pages•20 fields
Lymphedema Therapy Patient Intake FormUse this template