support@chronicoedema.com
support@chronicoedema.com
Chronic Oedema Solutions
ORGANISATION
HEALTH PROFESSIONAL
CARE WORKER
About
ABOUT COS
LES
Solutions
ROADMAP
EDUCATION
SCREENING PROGRAM
EARLY INTERVENTION
LOWER LIMB COURSE
CARE WORKERS
Contact
Log In
MY PROFILE
START AN ORDER
Chronic Oedema Solutions
ORGANISATION
HEALTH PROFESSIONAL
CARE WORKER
About
ABOUT COS
LES
Solutions
ROADMAP
EDUCATION
SCREENING PROGRAM
EARLY INTERVENTION
LOWER LIMB COURSE
CARE WORKERS
Contact
Log In
MY PROFILE
START AN ORDER
Help me with my order
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Step
1
of 2
Client
*
Female
Male
Age
*
Oedema History
Has the client been told they have lymphoedema or chronic oedema?
*
Yes
No
Which side is the oedema ( you can tick more than one)
Left Leg
Right Leg
How long has the client had oedema
*
When is the oedema present?
*
All day
End of the day
Other
Are there certain activities that aggravates the oedema?
*
What eases the leg oedema?
*
Does the swelling reduce with elevation?
*
Yes
No
Not sure
How much does it reduce ? eg 50%
Symptoms ( you can tock more than one)
*
Ache
weakness in the legs
Heaviness
Sharp pain
Pins and needles
Numbness
No symptoms
What position does the client sleep in?
Did your client have management of their lymphoedema prior to seeing you?
*
Yes
No
Provide details of the previous lymphoedema management
Medical History
Has the client got congestive cardiac failure
*
Yes
No
Don't know
How is it managed?
Has the client got hypertension
*
Yes
No
Don't know
How is it managed?
Has the client had cancer treatment
*
Yes
No
Don't know
How was it managed?
Has the client had a previous DVT?
*
Yes
No
Don't know
Provide details of when, where and management
Has the client had a past history of varicose vein surgery or treatment?
*
Yes
No
Don't know
Has the client have diabetes?
*
Yes
No
Don't know
Has the client got arthritis ?
*
Yes
No
Don't know
Provide details of where and any management.
Has the client any orthopaedic issues ( eg hip replacement)?
*
Yes
No
Don't know
Provide details of where and any management.
Has your client had cellulitis?
*
Yes
No
Don't know
Cellulitis History
Provide details, if available of when each episode of cellulitis occurred and its management.
Does the client leak fluid from their legs?
*
Yes
No
Don't know
Does the client have a leg ulcer?
*
Yes
No
Has the client had tests to investigate the oedema?
*
Yes
No
Don't know
Provide details
Has your client got any memory issues?
*
Yes
No
Don't know
Other Medical History
*
Provide details of the other relevant medical history that may impact on the management of the lymphoedema
Current Medication
*
What are your clients goals
*
Social and Activities of Daily Living History
Social History Details
Provide details of your client's social support
Does your client perform regular exercise ? eg walking
Yes
No
Not sure
Provide details of exercise
Objective Assessment - Observation
Upload photos of the leg (s)
Click or drag files to this area to upload.
You can upload up to 5 files.
If you don't have photos upload a body chart which indicates the location of the oedema
Click or drag files to this area to upload.
You can upload up to 2 files.
Observation Colour left leg
*
Normal
Pink
Red
Observation Colour right leg
*
Normal
Pink
Red
Skin quality of the left leg
*
Well hydrated
Dry
Skin breaks
Lymphorrhea
Where is it dry?
Where are the skin breaks?
Skin quality of the right leg
*
Well hydrated
Dry
Skin breaks
Lymphorrhea
Where is it dry?
Where are the skin breaks?
Objective Assessment - Palpation
Objective Assessment - Circumferences
Upload your chart with the circumferences for both legs
Click or drag a file to this area to upload.
Objective Assessment - Weight
What is the weight of your client?
Objective Assessment - Bioimpedance
Treatment
Which of the following treatment options will you use to treat the oedema in your clienst leg(s)
*
Education including skin care
Self manual lymphatic drainage / exercise
Exercise
Therapist manual lymphatic drainage
Compression garment
Wrap
Type in the garment measurements ( ie b, c, d circumferences, length of foot and leg)
*
What size garment do you suggest?
*
Size 4
Size 5
Size 6
Side 7
Size 8
Size 9
Size 10
Size 11
Size 12
Size 13
Size 14
Size 15
What is the width of the garment
*
Standard width
Extra wide
Length of garment
*
Short
Regular
Long
Foot length
*
Short
Regular
Long
Grip top
*
Yes
No
Which wraps are you planning of prescribing
*
Foot wrap
Leg wrap
Type in the wrap measurements ( ie circumferences and lengths)
*
What size foot wrap are you suggesting?
*
xsmall foot wrap
Small wrap
Medium foot wrap
Large foot wrap
Xlarge foot wrap
Regular length
Long length
What size leg wrap are you suggesting?
*
xsmall leg wrap
Small leg wrap
Medium leg wrap
Large leg wrap
Xlarge leg wrap
Short length
Regular length
Long length
What questions would you like answered regarding this client?
*
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