New Patient Questionnaire – Bayside Lymphoedema

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.

If you also need to book your appointment time, please click here -the appointment request form and new patient form can be completed together.

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

Mr/Mrs/Miss/Ms

First Name

Last Name

Your Email (required)

Best Contact Number

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:
Heart conditionBlood disordersHigh Blood PressureLow Blood PressureBreathing difficultiesIndigestion/stomach painUlcerConstipationDiarrheaKidney or urinary troubleMenstrual problemsDizzinessSleeplessnessFatigueHeadachesThyroid ProblemsHeadachesMigrainesStressNervousnessSinus conditionAnemiaHay FeverHIV CarrierVaricose VeinsVenous/Arterial DiseaseNeurological DiseaseDiabetesArthritisTuberculosisSkin DisordersAllergiesMemory LossCancerOther

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)
Please check this box to indicate you agree to the above terms.

Please type the letters shown below into the box

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

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