PAST MEDICAL HISTORY Please enclose summaries – HISTORY OF AFFECTED: Yes Give details No Site of Swelling: Signs of Infection: Yes Treatment: Give details No Evidence of Neuropathy: Yes No SOCIAL HISTORY: IS THERE AN ADVANCE CARE PLAN? YES NO If YES, please give details HAS THE PATIENT’S MENTAL CAPACITY BEEN ASSESSED? YES NO If YES, please give details; date and by whom? Is a Carer or Care Agency Contact details for Carer or Care Agency: involved? Yes No Is Patient able to attend the Is the patient housebound? Yes No clinic? Yes No Is Home required? Yes No If a Home Visit is required what are the access arrangements e.g. key codes etc?
PAST MEDICAL HISTORY – Please enclose summaries HISTORY OF AFFECTED: Yes Give details No Site of Swelling: Signs of Infection: Yes Give details No Treatment: Evidence of Neuropathy: Yes No SOCIAL HISTORY: IS THERE AN ADVANCE CARE PLAN? YES NO If YES, please give details HAS THE PATIENT’S MENTAL CAPACITY BEEN ASSESSED? YES NO If YES, please give details; date and by whom? Is a Carer or Care Agency involved? Yes No Contact details for Carer or Care Agency: Is Patient able to attend the clinic? Yes No Is the patient housebound? Is Home required? Yes No Yes No If a Home Visit is required what are the access arrangements e.g. key codes etc?
Alliance-Lymphoedema-Referral-Form-1.docx