Ardgowan Hospice Lymphoedema Referral Form

ARDGOWAN HOSPICE LYMPHOEDEMA REFERRAL FORM

All patients referred to the service must have contra-indications to treatment out ruled prior to referral:
IVC/SVC Obstruction, Uncontrolled Cardiac/Renal failure, Acute DVT, Cellulitis, PVD, Undiagnosed Recurrence of Malignancy
Patient Details
Surname / Title / Age / DOB / CHI
Forename / M / S / W / D / Male / Female
Address:
Postcode Telephone / Occupation
Religion
Patient Location
Consent obtained from Consultant / GP to treat patient?

General Practitioner Details

Name / Non-cancer lymphoedema
Please provide the name of the healthcare professional who will be responsible for ongoing management of the patient. Named person should make themselves available to attend with the patient if required.
Name and contact details:
Address
Postcode / Telephone

Reason for Referral: please tick all relevant boxes

Lymphoedema secondary to cancer / cancer treatment
Regional lymph node involvement
Regional skin involvement
Local recurrence
Distant mets / Lymphoedema secondary to venous disease
Lymphoedema secondary to trauma / recurrent infection
Lymphoedema secondary to limb dependency / immobility
Primary lymphoedema (congenital / hereditary)
Medical History
DVT (within the last 6 months)
Heart Failure
Hypertension
Hemiplegia
SVC Obstruction
Cellulitis
Diabetes
Lymphorrhoea
Venous disease
Thyroid disease
Arthritis
Chronic renal failure
Chronic skin disorder
Obesity - please state weight...... / Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes / No
No
No
No
No
No
No
No
No
No
No
No
No / Diagnosis (and histology with dates)
Is there evidence of venous or arterial insufficiency? Yes (give details) No
If yes, please provide ABPI and full assessment if carried out
History of swelling / onset / limb affected:
(Please tick if applicable):
Other areas affected: Digits Head and Neck Trunk Breast Genitals
Skin: Fragile Broken/ulcerated Taut/shiny Thickened
Limb weeping Tissue is non-pitting & fibrotic Limb distorted shape
Pain Recurrent infection
Current medications:
Any additional relevant past / current medical history:
Is the patient known to any other health care professionals? (Please give details)
NB Please attach a photocopy of recent clinic letters and recent blood results

Referrer Details: ……………………………………...... Designation……………………………..

Print Name…………………………………………………………...... Date……………………......

For use by Lymphoedema Service:
Referral received Urgent Routine
Appointment sent/phoned Outpatient Inpatient
Date/time of appointment

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