Image Forms Patient Progress Notes
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1PATIENT PROGRESS NOTES
Intimate Image Fax #: 818-876-7334 (Woodland Hills) 310-582-1972 (Santa Monica)
Patient: _______________________________
Phone: _____________
DOB: __________
Address:_______________________________ City:_______________
State:____ Zip Code:_______
Patient Requires:
Breast Prosthesis, Silicone – 1 per side every 2 years
Mastectomy Bras – 3 every 4 months
Breast Prosthesis; Leisure (Non-weighted) Form – 1 per side every 6 mths
Post-Op Camisole – Post-Op misc.- 2qt
Lymphedema Garments- Sleeve ____ Glove_____ Knee ____
Thigh _____
Panty Hose ______
Compression Level:
15-20 ___
20-30_____
30-40_____
Frequency of Use:
Daily: ____
Weekly: ____
Monthly: _____
Lifetime: ____
Diagnosis:
Cancer
Lymphadema
Diagnosis Code:
Rt Breast ____
Lt Breast ____
S/P Mastectomy___
RT ___ LT ___ _______________
Date Of Surgery___________
Clinical Status:
No Change ____
Improving _____
Declining _____
Any Further Breast Surgery Type: ____________ Date: _____________ Prognosis: ___________________
Date of Last Breast Exam: ___________________
Limitations: ______________________________________________________________________________
EXPLANATION/CLARIFICATION-Necessity of Above-Mentioned Item
_
:_________________________________
________________________________________________________________________________________
________________________________________________________________________________________
* Also any other notes pertaining to this condition.
_________________________________
_____________________________
________________
PHYSICIAN’S SIGNATURE
PRINTED NAME
DATE
*required every 12 months
Intimate Image 22941 Ventura Boulevard | Woodland Hills | CA 91364 | Phone: 818-876-7333 | Fax: 818-876-7334
2907 1/2 Santa Monica Boulevard | Santa Monica | CA 90404 | Phone: 310-582-1960 | Fax: 310-582-1972
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Parent category: Medical