PATIENT FORM

Please complete the form below, prior to your appointment. Don’t forget to click “Submit” at the end of the form. No need to print anything once you click submit.

Click on the following links for paper versions to print and fill-out: Medical Information Form or Registration Form

Haga clic en los siguientes enlaces para las versiones en papel para imprimir y rellenar: Forma De Información Médica o Forma de registro

Venous History

Please answer the following questions to the best of your ability

Please briefly describe your symptoms and what brings you in:

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  • - Gender -
  • Female
  • Male
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Risk Factors

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Location

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  • - select a state -
  • Alabama
  • Alaska
  • Arizona
  • Arkansas
  • California
  • Colorado
  • Connecticut
  • Delaware
  • District of Columbia
  • Florida
  • Georgia
  • Hawaii
  • Idaho
  • Illinois
  • Indiana
  • Iowa
  • Kansas
  • Kentucky
  • Louisiana
  • Maine
  • Montana
  • Nebraska
  • Nevada
  • New Hampshire
  • New Jersey
  • New Mexico
  • New York
  • North Carolina
  • North Dakota
  • Ohio
  • Oklahoma
  • Oregon
  • Maryland
  • Massachusetts
  • Michigan
  • Minnesota
  • Mississippi
  • Missouri
  • Pennsylvania
  • Rhode Island
  • South Carolina
  • South Dakota
  • Tennessee
  • Texas
  • Utah
  • Vermont
  • Virginia
  • Washington
  • West Virginia
  • Wisconsin
  • Wyoming
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Additional information

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How did you hear about us?

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Health Insurance

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Employment Status

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Marital Status

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Race

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Ethnicity

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Clinical

Current Medications

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Medication Allergies

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Pharmacy Name & Phone Number or Cross Streets

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History

Family History (Check all that apply)

Vein disease / varicose veins
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CVA
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Blood clots / phlebitis / DVT
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Peripheral Arterial Disease
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Cardiac / Disease Cardiovascular
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Social History

Do you smoke tobacco?

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Do you drink alcohol?

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Medical & Surgical History

Personal Medical History (Check all that apply)

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Please describe

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Surgical History

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Describe:
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Venous History

H&P / Vascular Check

Chief Complaint-Legs / Symptoms

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Started / Duration

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Timing

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Severity

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Exacerbated by

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How long have your legs bothered you?

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Does one leg bother you more than the other?

  • - select a option -
  • Left leg
  • Right leg
  • Both leg and right leg equally
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How much leg pain/discomfort have you had in the past 4 weeks?

  • - select a option -
  • No pain
  • Slight pain
  • Moderate pain
  • Considerable pain
  • Severe pain
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At what time of day are leg symptoms the worse?

  • - select a option -
  • On waking
  • At mid-day
  • At the end of the day
  • During the night
  • Any time of the day
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7) Have you ever worn compression stockings?

  • - select a option -
  • Yes
  • No
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6) Are leg symptoms made worse by heat?

  • - select a option -
  • Yes
  • No
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7a) Have you done leg exercises and leg elevation?

  • - select a option -
  • Yes
  • No
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8) Have you had lower extremity vein / vascular treatment in the past?

  • - select a option -
  • Yes
  • No
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9) Have you experienced any of the following symptoms within past 4 weeks? (Check all that apply):

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10) During the past 4 weeks, how much trouble have you had carrying out the actions and activities listed below because of your leg problems?

Remaining standing for a long time
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Doing certain jobs at home (e.g. standing and moving around in the kitchen, cleaning the floor, or other house projects...)
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Doing certain jobs at home (e.g. standing and moving around in the kitchen, cleaning the floor, or other house projects...)
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Going out for the evening, to a wedding, a party, a cocktail party...
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11) Leg problems can also affect your spirits. How closely do the following statements correspond to how you have felt during the past 4 weeks?

What is Your Occupation? (Explain)

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How does your symptom affect your job duties? (Explain)

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Does compression stockings help with your symptoms? (Explain)

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Does elevating your legs help? (Explain)

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Do you take over the counter or prescribed medications and does it help? (Explain)

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Do you have or feel any pain while sleeping? (Explain)

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How do you cope with that medication or compression stockings? (Explain)

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Do you smoke?

  • - select a option -
  • Yes
  • No
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Do you drink?

  • - select a option -
  • Yes
  • No
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Do you drink any caffeine?

  • - select a option -
  • Yes
  • No
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Are you diabetic?

  • - select a option -
  • Yes
  • No
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12) During past 4 weeks, to what extend did you feel bothered/limited in your work or your other daily activities because of your leg problems?

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13) During the past 4 weeks, did you sleep badly because of your leg problems, and how often?

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14) In the last 2 weeks for how many days did your veins cause you pain or ache?

Right leg pain
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Right leg pain
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15) During the past 2 weeks, on how many days did you painkillers or anti-inflammatories for your leg symptoms?

Right leg pain pills
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Left leg pain pills
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16) In the last 2 weeks, how much ankle swelling have you had?

Right leg swelling
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Right leg swelling
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