New Patient Registration

First Name *
Last Name *
Date of Birth (dd-mm-yyyy) *
Address *

Phone numbers:

Mobile *
Home
Work
Email Address *
Who is your GP? *
Do you have a lymphoedema therapist? YesNo
Name of lymphoedema therapist *
Address of lymphoedema therapist *
Are there any other specialists involved in your medical care that we should be aware of? YesNo
Please specify *

Triage and treatment related questions (please complete those that are applicable to you):

Height *
Weight * (Kilograms)
Have you had cancer? YesNo
Please specify region *

Have you had any of the following treatments for your cancer?

Radiation? YesNo
Chemotherapy? YesNo
Hormonal therapy? YesNo
Is there a family history of cancer? YesNo
Please note history *
Do you have lymphoedema? YesNo
What caused the onset of your lymphoedema? If a traumatic episode caused the onset of your lymphoedema please state the trauma suffered *
Which region of the body does your lymphoedema affect? *
How many years have you had lymphoedema? *
Current therapy regime for the treatment of your lymphoedema *

Do you have any of the following:

Diabetes? YesNo
Hypertension? YesNo
Heart Disease? YesNo
Are you a smoker? YesNo
Please list your current medications *
Do you have any allergies? YesNo
Please list your allergies. *