New Patient Health Questionnaire

Fiona Kent · MLD & Scar Therapist · Norwich

Please complete this form before your appointment. The information you provide will help Fiona prepare for your consultation and plan the most appropriate treatment. All information is kept strictly confidential.

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Thank you — questionnaire received

Fiona has been notified and will review your information before your appointment.
You'll also receive a confirmation email shortly.

Personal details

Full name *

Date of birth

Address

Telephone

Email address *

Emergency contact (name & number)

GP practice

Approximate weight (helps Fiona prepare)

st lbs

Home visit recommended

Fiona's practice may not be the most comfortable environment for you at this time. She is very happy to come to you instead — home visits are available at the same session rate plus mileage. Fiona will be in touch to discuss the best arrangement for you.

What brings you to the clinic?

What are you seeking treatment for? *

Which area(s) of your body are affected?

How long have you had this problem?

Less than 3 months 3–12 months Over 1 year

Medical history

Do you have, or have you previously had, any of the following?

Cancer (including surgery, chemotherapy or radiotherapy) Lymphoedema Diabetes Heart disease Kidney disease Venous disease / varicose veins Other significant medical condition(s)

Please give details if applicable (optional)

Medications & allergies

Please list any regular medications (or write 'none')

Do you have any allergies?

No Yes (please specify)

Your symptoms

Please tick any symptoms you currently experience:

Swelling Pain Tightness Heaviness Reduced movement Hard tissue / fibrosis Scar discomfort Skin changes Weeping skin Previous cellulitis Wounds / ulcers

Previous treatment

Have you received treatment for this condition before?

No Yes

If yes, please tick any that apply:

Compression garments Manual Lymphatic Drainage (MLD) Bandaging Scar therapy Physiotherapy

Other (optional)

Your goals

What would you like to achieve from treatment?

Consent & declaration

I confirm that the information I have provided is accurate to the best of my knowledge. I understand that this information will be kept strictly confidential and used only to inform my treatment.

Signature (full name) *

Date

Optional: clinical photography consent

I consent to clinical photographs being taken for the purpose of assessing and monitoring my treatment.

Yes No

Signature (full name)