ALL SECTIONS MUST BE COMPLETED PATIENT DETAILS REASONS FOR REFERRAL Surname Lymphoedema secondary to cancer /  First name cancer treatment. Address  If so, please tick the following if relevant: Regional lymph node involvement Postcode Telephone  Male / Female DOB Regional skin involvement  Email Ethnicity NHS Number Hospital number Local recurrence  GP DETAILS Distant mets  Name Address Lymphoedema secondary to venous  disease Lymphoedema secondary to limb  dependency / immobility Postcode Telephone Routine Urgent IS THE REFERRAL URGENT: Primary lymphoedema (congenital /    hereditary) SEE FLOW CHART GENERAL MEDICAL HISTORY DIAGNOSIS (with dates if known) Phlebitis Yes No   Yes No Varicose   Yes No Rheumatoid Arthritis   Yes No   Osteo-arthritis Yes No   Thyroid Surgical Interventions Yes No   Details Weight: Weight loss referral made: YES/NO BMI: Lymphoedema History: Oedema evident in: (please tick all appropriate) Face Arm(s) Chest Abdomen Genitals Leg(s) Other        Do you consider the oedema as Mild Moderate Severe Palliative     Is the patient complaining of pain Yes No Site of pain:  
ALL SECTIONS MUST BE COMPLETED PATIENT DETAILS REASONS FOR REFERRAL  Lymphoedema secondary to cancer / cancer treatment.  If so, please tick the following if relevant:  Regional lymph node involvement  Regional skin involvement  Local recurrence  Distant mets  Lymphoedema secondary to venous disease  Lymphoedema secondary to limb dependency / immobility  Primary lymphoedema (congenital / hereditary) Surname First name Address Postcode Telephone Male / Female DOB Email Ethnicity NHS Number Hospital number GP DETAILS Name Address Postcode Telephone IS THE REFERRAL URGENT: Routine  Urgent  SEE FLOW CHART GENERAL MEDICAL HISTORY Phlebitis Varicose Rheumatoid Arthritis Osteo-arthritis Thyroid Yes  No  Yes  No  Yes  No  Yes  No  Yes  No  DIAGNOSIS (with dates if known) Surgical Interventions Yes  No  Details Weight: Weight loss referral made: YES/NO BMI: Lymphoedema History: Oedema evident in: (please tick all appropriate) Face  Arm(s)  Chest  Abdomen  Genitals  Leg(s)  Other  Do you consider the oedema as Mild  Moderate  Severe  Palliative  Is the patient complaining of pain Yes  No  Site of pain:
Bromley-Lymphoedema-REFERRAL-FORM-Version-1-29.01.16.docx