Patient Name First Last Date MM slash DD slash YYYY Email Date of Birth MM slash DD slash YYYY Age Height Weight Sex Male Female Primary Care Physician Allergies or Reactions Past Medical History - Please check all that apply. Cancer (if yes, which type? Are you currently undergoing any treatments?) Please specify Past Medical History Lung Disease (asthma, emphysema, chronic bronchitis, other) Please specify Past Medical History Heart Disease (heart attack, coronary heart disease, arrhythmia, murmur, enlarged heart, heart failure, other) Please specify Past Medical History Diabetes (Insulin or Non-Insulin dependent) Please specify Past Medical History Hypertension (high blood pressure) Please specify Past Medical History Hypercholesterolemia (high cholesterol/triglycerides) Please specify Past Medical History Stroke Please specify Past Medical History Blood clots (phlebitis, DVT) Please specify Past Medical History Thrombophilia (HIT, Factor V Leiden, protein C/S deficiency, homocysteinemia, other) Please specify Past Medical History Infectious diseases (HIV, hepatitis, tuberculosis, other) Please specify Past Medical History Arthritis (osteo/rheumatoid) Please specify Past Medical History Neurological disorder (migraines, multiple sclerosis, myasthenia gravis, Parkinson's disease, Alzheimer's disease, other) Please specify Past Medical History Peripheral arterial disease Please specify Past Medical History Thyroid dysfunction (if yes, please specify) Please specify Past Medical History Gastrointestinal condition (GERD, PUD, colitis, liver disease, hemorrhoids, other) Please specify Past Medical History Skin disorders (psoriasis, eczema, idiopathic thrombocytopenic purpura, other) Please specify Medications Blood thinners (Aspirin, Plavix, Coumadin, other) Please specify Medications Hormone replacement therapy (HRT) or Contraception (oral, injection, other) Please specify Medications Other prescriptions Please specify Medications Other over the counter Please specify Medications Vitamins/Supplements Please specify Past Surgical HistoryVein surgery (stripping & ligation, phlebectomy, sclerotherapy, laser) Vein surgery (stripping & ligation, phlebectomy, sclerotherapy, laser) Which leg? When? Please specify Stents (hearts, carotid, peripheral/legs or arms) Stents (hearts, carotid, peripheral/legs or arms) Please specify Other Other Social History Smoking (Yes/No) Please specify. Please specify Social History Alcohol (Yes/No) Please specify. Please specify Social History Illegal drugs (Yes/No) Please specify. Please specify Social History Work history (standing occupation, i.e. teacher, hairdresser, retail, other) Please specify Social History Athletic history (if yes, please specify, i.e. sports. Injuries?) Please specify Social History Exercise history (if yes, please specify, i.e. weight lifting, running, kick boxing, other) Please specify Social History Ambulatory status (bedridden, wheelchair, walker, cane, limp, none) Please specify Family History: Varicose veins (who?) Please specify Family History: Blood clots (who?) Please specify Family History: Leg ulcers (who?) Please specify Child 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 both Types of veins bulging veins spider veins blue surface veins Symptoms pain aching throbbing cramping itching burning heaviness leg swelling fatigue restless legs Venous 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 Specify Does 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
