|
ID#
|
|
|
Post Mastectomy
|
Surgery Side
• • •
|
|
RX Type
|
Surgery Date
|
|
Revision Date
|
|
|
|
|
|
Previous Bandage/Garment Use
|
Affected Side
• • •
|
|
Skin
• • •
|
Touch Sensitivity
|
|
Measurements Taken
|
Compression Level
|
|
Care/ Wear Instructions Given
|
|
|
|
|
|
Measurements & Landmarks
|
|
