VEIN MEDICAL HISTORY
THE FOLLOWING INFORMATION WILL HELP YOUR PHYSICIAN PLAN YOUR CARE. PLEASE
COMPLETE THIS INFORMATION:
Male ____
Female ____
Height __________
Age __________
Weight __________
What problem are you seeking care for? ________________________________________________________________
How long have you had this problem? _________________________________________________________________
What symptoms do you have?
_____________________________________________________________________
Have you had blood clots in your legs before? _____Yes
Are you pregnant? _____Yes
_____No
_____No If yes, date of onset__________________
_____Unsure
Date of last menstrual cycle? _____________________
Does anything improve your symptoms? ________________________________________________________________
What makes your symptoms worse? ___________________________________________________________________
Are you now or have you ever worn compression stockings? _____Yes
_____No If yes, for how long?__________
When?___________________________________________
Have you ever had any procedures done for Varicose Veins or spider veins?____________________________________
Please rate the following on a scale of 0-5, with 0 being None and 5 being Severe
Swelling
Aching
Burning
Itching
0
0
0
0
1
1
1
1
2
2
2
2
3
3
3
3
4
4
4
4
5
5
5
5
Bleeding
Phlebitis (blood clots)
Heaviness
Swelling
0
0
0
0
1
1
1
1
2
2
2
2
3
3
3
3
4
4
4
4
5
5
5
5
Please rate the following level of pain on a scale of 0-3, with 0 being “No Pain” and 3 being “Severe Pain”
0 – No Pain
None
1 – Mild Pain
Occasional pain or other discomfort, not restricting daily activities.
2 – Moderate Pain
Daily pain or other discomfort, which interferes with, but does not prevent daily
activities.
3 – Severe
Daily pain or discomfort that limits most regular daily activities
PLEASE COMPLETE BOTH SIDES OF FORM
VC001 11/2013
In the past two weeks, have you had any problems with the following?
-
Fever, chills, night sweats, rapid weight loss _____Yes
_____No
Sight, Vision _____Yes
_____No
Runny nose, sore throat, or problems swallowing? _____Yes
No_____
Cough or shortness of breath? _____Yes
_____No
Chest pain? _____Yes
_____No
Nausea, vomiting, constipation, or diarrhea? _____Yes
_____No
Burning with urination? _____Yes
_____No
Bleeding or bruising easily? _____Yes
_____No
Problems clotting easily? _____Yes
_____No
Moving your arms or legs? _____Yes
_____No
Itchy skin or rashes? _____Yes
_____No
Numbness or tingling in your hands or feet? _____Yes
_____No
Depression? _____Yes
_____No
Check and or list all illnesses/problems you have been treated for in the past and present:
____ none
____ heart attack
____angina
____ diverticulitis
____ heart murmur
____ mitral valve prolapse
____ high blood pressure
____ crohn’s disease
____ stroke
____ asthma
____ low blood pressure
____ ulcerative colitis
____ blood clots
____ stomach trouble/ulcer
____ bleeding disorder
____ hepatitis
____ COPD
____ emphysema
____ kidney problems
____ seizures
____ bladder
____ arthritis
____ diabetes
____ tuberculosis
____ cancer
____ depression
____ cirrohsis
____ other – explain below
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Please list any surgeries you have had:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Does anyone in your family have problems with bleeding easily? _____Yes
Does anyone in your family have problems with blood clots? _____Yes
Do you smoke, drink alcohol, use drugs? _____Yes
_____No
_____No
_____No
_____Occasionally
Please list your medication allergies:____________________________________________________________________
_________________________________________________________________________________________________
What medications are you currently taking:_______________________________________________________________
Email address: __________________________________________________________
How did you hear about us? _____Friend _____Brochure _____Website_____ _____Referred from my doctor
_____Billboard _____Other (Please specify)_______________________________________________
PLEASE COMPLETE BOTH SIDES OF FORM
VC001 11/2013