Patient Name First Last Date MM slash DD slash YYYY Email Date of Birth MM slash DD slash YYYY AgeHeightWeightSex Male FemalePrimary Care PhysicianAllergies or ReactionsPast Medical History - Please check all that apply. Cancer (if yes, which type? Are you currently undergoing any treatments?)Please specifyPast Medical History Lung Disease (asthma, emphysema, chronic bronchitis, other)Please specifyPast Medical History Heart Disease (heart attack, coronary heart disease, arrhythmia, murmur, enlarged heart, heart failure, other)Please specifyPast Medical History Diabetes (Insulin or Non-Insulin dependent)Please specifyPast Medical History Hypertension (high blood pressure)Please specifyPast Medical History Hypercholesterolemia (high cholesterol/triglycerides)Please specifyPast Medical History StrokePlease specifyPast Medical History Blood clots (phlebitis, DVT)Please specifyPast Medical History Thrombophilia (HIT, Factor V Leiden, protein C/S deficiency, homocysteinemia, other)Please specifyPast Medical History Infectious diseases (HIV, hepatitis, tuberculosis, other)Please specifyPast Medical History Arthritis (osteo/rheumatoid)Please specifyPast Medical History Neurological disorder (migraines, multiple sclerosis, myasthenia gravis, Parkinson's disease, Alzheimer's disease, other)Please specifyPast Medical History Peripheral arterial diseasePlease specifyPast Medical History Thyroid dysfunction (if yes, please specify)Please specifyPast Medical History Gastrointestinal condition (GERD, PUD, colitis, liver disease, hemorrhoids, other)Please specifyPast Medical History Skin disorders (psoriasis, eczema, idiopathic thrombocytopenic purpura, other)Please specifyMedications Blood thinners (Aspirin, Plavix, Coumadin, other)Please specifyMedications Hormone replacement therapy (HRT) or Contraception (oral, injection, other)Please specifyMedications Other prescriptionsPlease specifyMedications Other over the counterPlease specifyMedications Vitamins/SupplementsPlease specifyPast Surgical HistoryVein surgery (stripping & ligation, phlebectomy, sclerotherapy, laser) Vein surgery (stripping & ligation, phlebectomy, sclerotherapy, laser)Which leg?When?Please specifyStents (hearts, carotid, peripheral/legs or arms) Stents (hearts, carotid, peripheral/legs or arms)Please specifyOther OtherSocial History Smoking (Yes/No) Please specify.Please specifySocial History Alcohol (Yes/No) Please specify.Please specifySocial History Illegal drugs (Yes/No) Please specify.Please specifySocial History Work history (standing occupation, i.e. teacher, hairdresser, retail, other)Please specifySocial History Athletic history (if yes, please specify, i.e. sports. Injuries?)Please specifySocial History Exercise history (if yes, please specify, i.e. weight lifting, running, kick boxing, other)Please specifySocial History Ambulatory status (bedridden, wheelchair, walker, cane, limp, none)Please specifyFamily History: Varicose veins (who?)Please specifyFamily History: Blood clots (who?)Please specifyFamily History: Leg ulcers (who?)Please specifyChild Rearing History Are you pregnant? (Yes/No) Do you intend to become pregnant in the next year? (Yes/No) Are you currently breastfeeding? (Yes/No) How many pregnancies have you had? How many births?Venous Review of SymptomsWhich leg is affected? left right bothTypes of veins bulging veins spider veins blue surface veinsSymptoms pain aching throbbing cramping itching burning heaviness leg swelling fatigue restless legsVenous Symptomatic ManagementDo you wear or have you worn compression stockings? Do you wear or have you worn compression stockings?When?For how long?Did they help?Do you take medicine for pain? If yes, what do you take? Do you take medicine for pain? If yes, what do you take?Please SpecifyDoes anything else relieve your symptoms? Does anything else relieve your symptoms?Please state your personal priority and goal for vein treatmentDate MM slash DD slash YYYY
