East Coast Cardiology
Venous Health History Form
Please complete the following questions before your ultrasound.
Patient Name: _____________________________________ Date of Birth: _______________
Past Medical History
1. Have you ever had vein stripping surgery? Yes ____
No ____
If yes, when and which leg? _________________________________________
2. Have you ever had vein injections?
Yes ____
No ____
If yes, when and which leg? _________________________________________
3. Have you ever had a blood clot?
Yes ____
No ____
If yes, when and which leg? _________________________________________
4. Have you ever had phlebitis?
Yes ____
No ____
If yes, when and which leg? _________________________________________
Family History
Does anyone in your family have (or used to have) varicose veins, spider veins, leg ulcers, or
swollen legs?
Father
Yes ____
No ____
Mother
Yes ____
No ____
Brother
Yes ____
No ____
Sister
Yes ____
No ____
Other
Yes ____
No ____
1. Do you experience any of the following in your legs?
Aching /pain?
Yes ____ No ____ Which Leg? _____________________________
Heaviness?
Yes ____ No ____ Which Leg? _____________________________
Tiredness/fatigue? Yes ____ No ____ Which Leg? _____________________________
Itching/burning?
Yes ____ No ____ Which Leg? _____________________________
Swollen ankles?
Yes ____ No ____ Which Leg? _____________________________
Leg cramps?
Yes ____ No ____ Which Leg? _____________________________
Restless legs?
Yes ____ No ____ Which Leg? _____________________________
Throbbing?
Yes ____ No ____ Which Leg? _____________________________
Vas Scale – Rate your intensity of pain ______________________
Is the pain persistent? Yes ____ No ____
2. Have your veins gotten worse in recent months?
Yes ____ No ____
Describe: _____________________________________________________________
3. Do you take any medications for pain?
Yes ____ No ____
If yes, what medication(s)? _______________________________________________
4. Do you elevate you legs to relieve discomfort?
Yes ____ No ____
If yes, how long per day and does it provide relief? _____________________________
5. Do you exercise?
Yes ____ No ____
If yes, what kind of exercise and how often? _________________________________
6. Do you wear compression stockings?
Yes ____ No ____
If yes, what type and gradient? How long have you worn them? ___________________
_____________________________________________________________________
If yes, what is the name of the physician who prescribed your compression stockings and
when were they prescribed? _______________________________________________
7. Do you have any problems walking?
Yes ____ No ____
If yes describe how it interferes with activities of daily living, which activities? (Work,
shopping, showering, cleaning, playing with children etc.) Is it worse at night?
________________________________________________________________________
________________________________________________________________________
8. What type of work do you do? _______________________________________________
How long do you stand (hours per day) at work? ___________ At home? ____________
9. Have you ever had any test done on your veins?
Yes ____ No ____
If yes, when and what type of test and where on the leg? __________________________
________________________________________________________________________
10. Were you diagnosed with venous reflux?
Yes ____ No ____
Patient Signature: _________________________________________ Date: ___________