Get Lymphedema Physical Therapy Evaluation Form

Filling out the Lymphedema Physical Therapy Evaluation Form online is an important step in managing lymphedema and receiving appropriate care. This guide will walk you through each section of the form, ensuring that you complete it accurately and efficiently.

Follow the steps to fill out the Lymphedema Physical Therapy Evaluation Form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin with entering the patient’s name and the date at the top of the form. Make sure all personal information is correct and up to date.
3. Next, fill in the patient's height and weight details. Indicate if the condition is bilateral by selecting the appropriate checkbox.
4. Enter the patient’s date of birth (DOB) along with contact information for the treating physician, their phone number, and the primary care physician (PCP) information.
5. Complete the patient medical history section. Answer whether the patient has any open wounds, if they have a history of cancer, or if they have used compression therapy in the past. This information is crucial for the evaluation.
6. In the following questions, indicate if the patient has lymphedema and if there are any physical deformities or abnormalities in the affected areas.
7. Proceed to fill in any relevant medical history concerning blood clots, cellulitis, congestive heart failure, or chronic venous insufficiency by answering yes or no.
8. For the lymphedema pump information, select the type of pump being used and fill in the settings and pressure. Include the frequency of use and duration as applicable.
9. Provide measurements for the affected areas using inches. Ensure measurements are accurate for best results, ideally taken in the morning or immediately after compression therapy.
10. Finally, include the name and signature of the person completing the form along with the date.
11. Once the form is filled out, you can save changes, download, print, or share the completed document.

Complete your Lymphedema Physical Therapy Evaluation Form online to ensure timely care.