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PATIENT PROGRESS NOTES Intimate Image Fax : 818-876-7334 (Woodland Hills) 310-582-1972 (Santa Monica) Patient: Phone: Address: City: Patient Requires: DOB: State: Zip Code: □ 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 Compression Level: Frequency of Use: □ Daily: □ Weekly: Diagnosis: Knee 15-20 □ Monthly: Cancer Rt Breast Lt Breast Thigh 20-30 30-40 □ Lifetime: Lymphadema S/P Mastectomy Panty Hose Diagnosis Code: 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..
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