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Client Health Record # Client Surname Given Name Date of Birth Gender MFRN PHIN Address (home visits only) Physician Referral Form for Lymphedema Assessment BREAST HEALTH CENTRE 100 - 400 Taché Avenue Winnipeg, MB R2H 3C3 www.wrha.mb.ca/bhc Toll Free: 1-888-501-5219 Telephone: 204-235-3684 Fax: 204-231-3842 Referring Physician Patient Information Name Address Address Phone Phone - Home Fax Phone - Work Provider # Phone - Cell Authorized Clinician Signature Weight (kg) Date (DD/MMM/YYYY) Height (cm) Reason for Referral Comorbid Conditions Lymphedema Therapy Approximate Onset: D D M M M Y Y Y Y Sudden onset Gradual onset Result of: Injury Insect Bite Infection Unknown Other ��������������������������� Assessment/Treatment of Frozen Shoulder Axillary Web Syndrome (Cording) Other Musculoskeletal Conditions Related to Breast Surgery Specify: ������������������������� Cardiac Disease Hypertension Cellulitis Hypotension CHF Pacemaker CVI Skin Condition on Surgery Side Diabetes Stroke/TIA DVT Vascular Disease Heart Attack/MI Metastatic Cancer Area involved: ��������������������������������������������������� Previous Cancer Area involved: ��������������������������������������������������� Treated Untreated Other (specify): ����������������������������������������������������� Right Breast Surgery Year Surgery Performed ����������� Procedure: Sentinel Node Dissection Axillary Lymph Node Dissection Lumpectomy Partial Mastectomy Modified Radical Mastectomy Simple Mastectomy Reconstruction Implants DIEP SGAP LD TRAM SIEA TUG Left Breast Surgery Year Surgery Performed ����������� Procedure: Sentinel Node Dissection Axillary Lymph Node Dissection Lumpectomy Partial Mastectomy Modified Radical Mastectomy Simple Mastectomy Reconstruction Implants DIEP SGAP LD TRAM SIEA TUG Additional Comments: Right Breast Treatment Chemotherapy Year ����������� Radiation Year ����������� Area treated: Axilla Chest wall Breast Supraclavicular Left Breast Treatment Chemotherapy Year ����������� Radiation Year ����������� Area treated: Axilla Chest wall Breast Supraclavicular Legend: CHF - Congestive Heart Failure SGAP - Superior Gluteal Artery Perforator CVI - Chronic Venous Insufficiency SIEA - Superficial Inferior Epigastric Artery DIEP - Deep Inferior Epigastric Perforator TIA - Transient Ischemic Attack DVT - Deep Vein Thrombosis TRAM - Transverse Rectus Abdominus Muscle LD - Latissimus Dorsi TUG - Transverse Upper Gracilis MI - Myocardial Infarction FORM # WCC-00148 10/12

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Page 1: Physician Referral Form for Lymphedema Assessment · Client Health Record # Client Surname ... MFRN PHIN Address (home visits only) Physician Referral Form for Lymphedema Assessment

Client Health Record #

Client Surname

Given Name

Date of Birth

Gender

MFRN

PHIN

Address (home visits only)

Physician Referral Form forLymphedema Assessment

BREAST HEALTH CENTRE100 - 400 Taché AvenueWinnipeg, MB R2H 3C3www.wrha.mb.ca/bhcToll Free: 1-888-501-5219Telephone: 204-235-3684Fax: 204-231-3842

Referring Physician Patient Information

Name Address

Address

Phone Phone - Home

Fax Phone - Work

Provider # Phone - Cell

Authorized Clinician Signature Weight (kg)

Date (DD/MMM/YYYY) Height (cm)

Reason for Referral Comorbid Conditions

Lymphedema TherapyApproximate Onset:

D D M M M Y Y Y Y

Sudden onset Gradual onset

Result of: Injury Insect Bite Infection Unknown Other ���������������������������

Assessment/Treatment of Frozen Shoulder

Axillary Web Syndrome (Cording)

Other Musculoskeletal Conditions Related to Breast Surgery

Specify: �������������������������

Cardiac Disease Hypertension Cellulitis Hypotension CHF Pacemaker CVI Skin Condition on Surgery Side Diabetes Stroke/TIA DVT Vascular Disease Heart Attack/MI Metastatic Cancer

Area involved: ���������������������������������������������������

Previous Cancer Area involved: ���������������������������������������������������

Treated Untreated Other (specify): �����������������������������������������������������

Right Breast SurgeryYear Surgery Performed �����������

Procedure: Sentinel Node Dissection Axillary Lymph Node Dissection Lumpectomy Partial Mastectomy Modified Radical Mastectomy Simple Mastectomy Reconstruction

Implants DIEP SGAP LD TRAM SIEA TUG

Left Breast SurgeryYear Surgery Performed �����������

Procedure: Sentinel Node Dissection Axillary Lymph Node Dissection Lumpectomy Partial Mastectomy Modified Radical Mastectomy Simple Mastectomy Reconstruction

Implants DIEP SGAP LD TRAM SIEA TUG

Additional Comments:

Right Breast Treatment Chemotherapy Year �����������

Radiation Year �����������

Area treated: Axilla Chest wall Breast Supraclavicular

Left Breast Treatment Chemotherapy Year �����������

Radiation Year �����������

Area treated: Axilla Chest wall Breast Supraclavicular

Legend:CHF - Congestive Heart Failure SGAP - Superior Gluteal Artery PerforatorCVI - Chronic Venous Insufficiency SIEA - Superficial Inferior Epigastric ArteryDIEP - Deep Inferior Epigastric Perforator TIA - Transient Ischemic AttackDVT - Deep Vein Thrombosis TRAM - Transverse Rectus Abdominus MuscleLD - Latissimus Dorsi TUG - Transverse Upper GracilisMI - Myocardial Infarction

FORM # WCC-00148 10/12

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