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. *
