Lymphoedema Volume Measurement Form

Patient Name: Sánchez Disano Jeremias Patient Number: Sheet #:

Affected Side: R R L B Dominant Side: R RL 24 cm
Hand/Foot Point: ______ Start Point: ______ cm
Date of Visit:
Hand/Foot RIGHT LEFT RIGHT LEFT RIGHT LEFT RIGHT LEFT RIGHT LEFT
Circumference:
D I S T A L
DISTAL 1 30 25
DISTAL 2 34 26
DISTAL 3 37 29
DISTAL 4 39 40
DISTAL 5 46 42
DISTAL 6 49 41
DISTAL 7 50 40
DISTAL 8 52
DISTAL 9 53
DISTAL 10 23
Distal Volume ml = 24
P R O X I M A L
PROXIMAL 1 56 43
PROXIMAL 2 62 48
PROXIMAL 3 67 50
PROXIMAL 4 74 54
PROXIMAL 5 77 61
PROXIMAL 6
PROXIMAL 7
PROXIMAL 8
PROXIMAL 9
PROXIMAL 10
Proximal Volume mls =
Total Volume mls =
Excess mls =
Excess % =
+ / - since last volume =
+ / - since Rx. Start =
Distal Vol. Difference: mls % mls % mls % mls % mls %
Proximal Vol. Difference: mls % mls % mls % mls % mls %
DP Ratio:
Weight Kg BMI
Notes:

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