If you would like to organise an appointment with us, you may request one using the form below. We will then get in touch with you as soon as we can.

If you have already made an appointment and need to complete the new patient questionnaire, click here to be redirected to the new patient form only

Alternatively, if you would prefer to call us or have any other queries you can contact us via our Contact Us page.

The information which you provide on this form is 100% confidential and will not be released outside our clinic under any circumstances.

 

This form may change and request additional information depending on your responses. It may also seem quite lengthy, but all information requested is important, so please complete it as accurately as possible. If you don’t understand any of the questions, don’t stress -we can sort that out at the time of your appointment.

Mr/Mrs/Miss/Ms

First Name

Last Name

Your Email (required)

Best Contact Number

Preferred Appointment Date & Time

Alternative Appointment Date & Time

Please provide any additional notes/comments here

Have you had an appointment with Bayside Lymphoedema before?

If this is your first appointment with Bayside Lymphoedema, you are required to also fill out our New Patient Questionnaire below. We understand that this questionnaire is quite long. Please fill in as much as possible and click the "send" button at the bottom.

Your Address (With Postcode)

Date of birth

Height

Weight (in Kg)

Next of Kin (Name, Relation & Phone Number)

Your Occupation

Who referred you to Bayside Lymphoedema?

Name and address of Primary Care Physician/GP

Date of last visit to GP and reason for Visit

Names of Other Doctors attended recently and reason for visits

Are you currently seeing a Surgeon?

YesNo

What is the name of your Surgeon?

Are you currently seeing an Oncologist?

YesNo

What is the name of your Oncologist?

Are your currently seeing a Radiotherapist?
YesNo

What is the name of your Radiotherapist?

Have you attended another Natural Therapist before?
Yes, I am currently seeing a Natural TherapistYes, I have seen a Natural Therapist in the pastNo

What is the name of your other Natural therapist?

What is your reason for needing Lymphoedema Massage

Are you, or is there a possibility you are pregnant?

DIAGNOSIS

Do you have...?
Primary LymphoedemaSecondary LymphoedemaLipoedema

At what age did your swelling first appear?

Check if you have had any of the following diagnostic tests done recently:
Blood TestsMammogramUltrasoundPap SmearCT ScanMRI ScanX-Ray

Are you currently experiencing any of the following Symptoms
SwellingCordingReddened SkinRestriction of movement in LimbDimpling in SkinHardening of Scar(s)

Have you had Cellulitis?
Yes, I currently have cellulitisYes, I have previously had cellulitisNo

Are you currently having, or have you previously had, treatment for Lymphoedema?
Yes, I am currently having treatmentYes I have previously had treatmentNo

When did you last have treatment for Lymphoedema

PAST MEDICAL HISTORY

Have you had any operations?
Axillary ClearanceSentinel Node BiopsyOther Operation

What year was your axillary clearance?

What year was your Sentinel Node Biopsy?

What other operations have you had and what year were they performed?

Have you had any lymph nodes removed?

How many nodes were removed?

What is your Cancer Status (if applicable)?

Do you have any family history of cancer?

Please provide details of family cancer history

Are you currently having any of the following:
ChemotherapyRadiotherapyHormone Therapy

What is the name of the hormone therapy you are receiving?

Have you had any recent illnesses/falls/accidents?

Please provide details of the illness/fall/accident, including the year

Are you currently taking any medications, vitamins, herbal medications?

Please list all medications/vitamins/herbal medications.

Do you have any known allergies?

Please specify your allergies

Health status: Please tick whichever of the following you have had or do have:

I understand that this clinic does not hold accounts. I agree to pay for treatments at the time of consultation. (We accept Cash, Eftpos, Mastercard, Visa. We do not accept Cheques)

(The above agreement must be ticked before this form can be sent)

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