Compression Pump Intake Form

Questions?

We are happy to help you fill this out:

Call 800-883-1549
Text (517) 657-5223

Please answer to the best of your ability. Answer only the questions that apply to you.

About you

First name

Last name

Date of birth

Phone

Email address

Referring physician

Reason for visit

Home and daily life

Home environment (check all that apply)

Apartment

One-story home

Multi-level home

Assisted living / nursing facility

Lives alone

Lives with someone

Other

If you live with someone or chose Other, please explain

Occupation

Retired Employed Other

If employed or other, please explain

Leisure activities / hobbies

Do you have any limitations in range of movement?

Yes No

If yes, what are they?

Do you have any limitations in daily activities because of your condition?

Yes No

If yes, what are they?

Do you need help getting washed or dressed?

Yes No

Pump safety questions

Please answer each question. These help us and your doctor make sure a compression pump is safe for you.

Do you have congestive heart failure that is not under control?

Yes No

Do you have an infection in the swollen arm or leg (such as cellulitis) that is not being treated with antibiotics?

Yes No

Do you have a deep vein thrombosis (DVT – blood clot in the leg)?

Yes No

Do you have a pulmonary embolism (blood clot in the lung)?

Yes No

Do you have lymphangiosarcoma (a rare cancer of the lymph vessels)?

Yes No

Do you have inflammatory phlebitis (inflamed vein, usually caused by a blood clot)?

Yes No

Do you have an IVC (inferior vena cava) filter?

Yes No

Allergies

Do you have any of these allergies?

Latex allergy

Adhesive allergy

None of these

Cancer history

Do you have a history of cancer?

Yes No

If yes, type of cancer

Location

Did you have surgery for it?

Yes No

If yes, type of surgery and date(s)

Mastectomy?

Yes No

Lymph nodes removed?

Yes No

Number of nodes removed

Number of nodes positive for cancer (if known)

Swelling (edema / lymphedema) history

Do you have swelling?

Yes No

Where is the swelling?

When did your swelling begin?

Does it go down at night?

Yes No

What makes it worse?

What makes it better?

Have you had treatment for your swelling before?

Yes No

If yes, when and where?

Do you use, or have you used, any of these for your swelling? (check all that apply)

Compression garments (socks, sleeves, etc.)

Compression pump

Bandaging / self-massage

Diuretics ("water pills")

Elevation / exercise

Manual lymphatic drainage (MLD)

Do you have any wounds?

Yes No

If yes, where?

Who is currently treating your wounds?

Do you have congestive heart failure?

Yes No

If yes, are you seeing a doctor for it?

Yes No

Heart failure provider name

Provider phone

Do you already have a compression pump?

Yes No

If yes, when did you get it?

Did you have the same insurance when you got your current pump?

Yes No

Other information

Do you have any pain?

Yes No

If yes, where?

How long does the pain last?

Constant Comes and goes

How would you rate your overall health?

Excellent Very good Fair Poor

What are your goals for therapy?

Do you have family or friends who can help you with therapy if needed?

Yes No

Are you getting home health services now (home nurse, therapist, nurse aide)?

Yes No

If yes, company or provider name and phone

Please list any other medical professionals you see

Authorization

I authorize Midwest Compression to use this information to work with me, my doctors and my insurance to obtain a compression (lymphedema) pump.

I agree to the authorization above

Type your full name (patient or authorized representative)

Today’s date

If filling this out for the patient, your relationship to the patient

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