West Suffolk Alliance Lymphoedema Service Referral Form

Please complete all sections

Patient Details
Patient Name: / Date of Birth:
Known as: / NHS Number:
Address:
(incl. postcode) / Next of Kin:
(incl. contact details)
Telephone: / Male/Female:
Mobile: / Ethnicity:
Communication Needs/Barriers: / Yes (please specify)
No
Yes No / Is patient aware of diagnosis? / Yes No
GP: / GP Telephone Number:
GP Address: / GP Aware of referral: / Yes
No
Other Professionals Involved (including contact details):
Hospital Consultant: / District Nurse:
Specialist Nurse: / Care Agency:
Lymphoedema History
Site of Swelling:
(please tick all appropriate and specify left or right) / Arm(s) Breast Head Genitals
Leg(s) Trunk Neck Other specify:
Severity of Swelling: / Mild Moderate Severe Palliative
Onset of Swelling: / Duration of Swelling:
Is patient complaining of pain? / Yes No Site:
Is Swelling Cancer Related? / Yes No
Known Cause of Swelling:
Treatment/Management to date:
Skin Condition / Intact Wounds (site): Ulcerated (site):
Lymphorrhoea Papillomatosis: Hyperkerratosis
Other (please specify) District Nurse involved
Past Medical History
Cancer History: / N/A
Diagnosis / Date of Diagnosis:
Surgery: / Yes No
Procedure: / Date of Procedure:
Nodes Removed: / Yes No / Number Positive:
Chemotherapy: / Yes No / Type:
Radiotherapy: / Yes No / Site:
Active Disease: / Yes No / Palliative: / Yes No
Relevant Medical History:(please complete/include patient summary)
Yes / No / Not Known / Controlled / Details
Hypertension
Heart Failure
Peripheral Vascular Disease/ Arterial Embolism
DVT (within last 6/12)
Chronic Renal Failure
Chronic Skin Disorders
Osteoarthritis
Rheumatoid Arthritis
Diabetes(including neuropathy)
Obesity
Thyroid
Hemiplegia
Cellulitis(no. of episodes in last 12 months)
Phlebitis
Psychiatric History
SVC Obstruction:
Venous Disease
Allergies (please specify)
Cognitive Impairment
Other (please specify – including previous surgery):
Is there an advance care plan? / Yes No / Is there a Yellow Folder? / Yes No
Current Medication:
(please list or attach)
ABPI / Left: Right: Date Performed:
Resus Status if Known:
Additional Patient Information
Height (m) / Weight (kg) / BMI
Mobility Status: / Fully Mobile Mobility Aid Assistance
Wheelchair Bound Housebound Comments:
Able to Attend Clinic: / Yes No
Home Visit Required:
Additional Information (e.g. access, keysafe, pets history of aggression, environmental, smoking) / Yes No
Please include a copy of results of blood tests for urea & electrolytes, thyroid function, full blood counts in addition to Doppler Study results, GP summary, current medication list and any recent hospital correspondence.
Referrer Details
Name: / Position:
Address: / Telephone:
Date Referral Completed:

Please email completed referral form to: Suffolk GP Federation Referral Booking Service:

Further questions please contact: 0345 241 3313 option 3.

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