New Patient Questionnaire

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
Name*
First Last
Email*
Best Contact Phone Number
Address*
Address Address Line 2 Suburb / City State Post Code
Date of birth*
DD slash MM slash YYYY
Height*
Weight (in kgs)*
Next of Kin (Name, Relation & Phone Number)*
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?
- Yes
- No
What is the name of your Surgeon?
Are you currently seeing an Oncologist?
- Yes
- No
What is the name of your Oncologist?
Are your currently seeing a Radiotherapist?
- Yes
- No
What is the name of your Radiotherapist?
Have you attended another Natural Therapist before?
- Yes, I am currently seeing a Natural Therapist
- Yes, I have seen a Natural Therapist in the past
- No
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?
- Yes
- No
Do you have...?
- Primary Lymphoedema
- Secondary Lymphoedema
- Lipoedema
At what age did your swelling first appear?
Check if you have had any of the following diagnostic tests done recently:
- Blood Tests
- Mammogram
- Ultrasound
- Pap Smear
- CT Scan
- MRI Scan
- X-Ray
Are you currently experiencing any of the following Symptoms
- Swelling
- Cording
- Reddened Skin
- Restriction of movement in Limb
- Dimpling in Skin
- Hardening of Scar(s)
Have you had Cellulitis?
- Yes, I currently have cellulitis
- Yes, I have previously had cellulitis
- No
Are you currently having, or have you previously had, treatment for Lymphoedema?
- Yes, I am currently having treatment
- Yes I have previously had treatment
- No
When did you last have treatment for Lymphoedema
Have you had any operations?
- Axillary Clearance
- Sentinel Node Biopsy
- Other 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?
- Yes
- No
How many nodes were removed?
What is your Cancer Status (if applicable)?
Do you have any family history of cancer?
- Yes
- No
Please provide details of family cancer history
Are you currently having any of the following:
- Chemotherapy
- Radiotherapy
- Hormone Therapy
What is the name of the hormone therapy you are receiving?
Have you had any recent illnesses/falls/accidents?
- Yes
- No
Please provide details of the illness/fall/accident, including the year
Are you currently taking any medications, vitamins, herbal medications?
- Yes
- No
Please list all medications/vitamins/herbal medications.
Do you have any known allergies?
- Yes
- No
Please specify your allergies
Health status: Please tick whichever of the following you have had or do have:
- Heart condition
- Blood disorders
- High Blood Pressure
- Low Blood Pressure
- Breathing Difficulties
- Indigestion/stomach pain
- Ulcer
- Constipation
- Diarrhea
- Kidney or urinary trouble
- Menstrual problems
- Dizziness
- Sleeplessness
- Fatigue
- Headaches
- Thyroid Problems
- Migraines
- Stress
- Nervousness
- Sinus condition
- Anemia
- Hay Fever
- HIV carrier
- Varicose Veins
- Venous/Arterial Disease
- Neurological Disease
- Diabetes
- Arthristis
- Tuberculosis
- Skin Disorders
- Allergies
- Memory Loss
- Cancer
- Other
*
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)

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Our Location

130 Male Street
Brighton, Melbourne VIC 3186

5 Minute walk from North Brighton Railway Station