Lymphedema Therapy Patient Intake Form
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Lymphedema Therapy Patient Intake Form
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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.
How to use the Lymphedema Therapy Patient Intake Form
Getting started with this template takes just a few minutes. Sign up for a free Formisoft trial, then select the Lymphedema Therapy Patient Intake Form from the template library. The form is ready to use immediately, but you can customize every field, add your practice logo, and adjust the layout to match your workflow.
Setup steps
- 1Choose the template. Find the Lymphedema Therapy Patient Intake Form in the template library and click “Use this template” to add it to your account.
- 2Customize fields. Add, remove, or reorder any of the 18 fields. Set fields as required or optional based on your practice needs.
- 3Brand it. Upload your logo, pick your colors, and add a custom welcome message so patients see your practice identity.
- 4Share with patients. Send the form via SMS, email, or embed it on your website. Patients complete it on any device before their visit.
- 5Review submissions. Responses appear in your dashboard in real time. Patient records are created automatically from the data collected.
Frequently asked questions
Is the Lymphedema Therapy Patient Intake Form HIPAA compliant?
Yes. All Formisoft templates, including the Lymphedema Therapy Patient Intake Form, are HIPAA compliant. Data is encrypted with 256-bit AES at rest and TLS 1.3 in transit. A Business Associate Agreement (BAA) is included on every plan.
Can I customize the fields in this template?
Absolutely. You can add, remove, reorder, or modify any of the 18 fields. You can also add conditional logic, new pages, file uploads, e-signatures, and payment fields.
How do patients fill out this form?
Patients receive a link via SMS, email, or QR code. They complete the form on their phone, tablet, or computer before their appointment. No app download required.
Can I send this form automatically before appointments?
Yes. Formisoft's workflow automation can send intake forms automatically when an appointment is booked. You can set the timing (e.g., 48 hours before the visit) and include reminders for patients who haven't completed it.
Does this template work on mobile devices?
Yes. The Lymphedema Therapy Patient Intake Form is fully responsive and works on any device. Most patients complete intake forms on their phone, so every template is optimized for mobile-first use.
Start with this template
Sign up and start customizing the Lymphedema Therapy Patient Intake Form for your practice. Set up in minutes.
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