Compression Garment Screening Form
Use this form to screen fit, sizing, intended use, and suitability details for a compression garment recommendation.
Applicant Information
Applicant Name
*
First Name
Middle Name
Last Name
Preferred Contact Method
*
Email
Phone
Text
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Follow-up Language
Please Select
English
Spanish
French
Other
Compression Garment Need and Intended Use
Reason for Seeking a Compression Garment
*
Swelling
Support
Post-activity Recovery
Travel
Post-procedure Guidance
Other
Body Area to Be Covered
*
Arm
Hand
Leg
Ankle/Foot
Torso
Other
Intended Use Timing
*
Daily Wear
Occasional Wear
During Activity
After Procedure
Other
Brief Description of Situation or Goal
Current Garment and Fit Details
Do you currently have a compression garment?
*
Yes
No
Current garment type
Please Select
Stocking
Sleeve
Glove
Wrap
Sock
Torso garment
Other
Current size or fit concerns
Preferred compression level
Please Select
Light
Moderate
Firm
Extra firm
Not sure
Brand or model, if available
How does the garment fit?
Comfortable
Too tight
Too loose
Causes slipping
Health and Screening Questions
Do you currently have swelling in the area where the garment will be worn?
*
No
Mild
Moderate
Severe
Unsure
Do you have pain or discomfort in that area?
*
No
Mild
Moderate
Severe
Unsure
Are you experiencing any of the following in the area?
Skin irritation or rash
Numbness or tingling
Coldness or color change
Tightness or pressure concerns
Other
Have you had a recent surgery or procedure related to the area?
No
Yes
Unsure
Do you have any open wounds or skin breakdown in the area?
*
No
Yes
Unsure
Have you been advised to avoid compression or to seek medical guidance before using compression?
*
No
Yes
Unsure
Additional health notes relevant to screening
Measurement and Sizing Information
Measurement Type
*
Limb circumference and length
Chest, waist, and hip
Other body area measurements
Chest Circumference (cm)
Waist Circumference (cm)
Hip Circumference (cm)
How Were Measurements Taken?
*
Self-measured
Taken by fitter
Taken by provider
Measured by another person
Other
Sizing Chart or Reference Available?
*
Yes
No
Outcome and Next Step
Desired outcome or recommendation request
*
Size recommendation
Product guidance
Follow-up fitting
Replacement
Other
Would you like a fitting follow-up or product suggestion based on your screening answers?
*
Yes
No
Additional notes or special fitting instructions
Submit
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