IMPROVE YOUR QUALITY OF LIFE! SM
MEDICAL HISTORY: WOMEN
Name:
Date:
Age:__________
Height:__________
Weight:___________
Occupation: _________________
HOW DID YOU LEARN ABOUT US?
Referring Physician:_______________________________________________________________
One of Our Other Patients (Name): ___________________________________________________
Internet
www.veindirectory.org
Yellow Pages
The Leaf Chronicle
The Great Escape Theatre
Cable Television
Fox News
CNN
Home And Garden
Food Channel
Other
Radio Station______________________________
Other
________________________________
Describe your symptoms in your own words:______________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
When did the symptoms described above begin? ___________________________________________
___________________________________________________________________________________
Do You Have?
Location (Leg) (Circle)
Red Spider Veins
R
Purple Veins
R
Bulging Veins
R
Flat Blue Green Veins
R
Skin Discoloration Below the Knee
R
Abdominal Veins
R
Abnormal Veins of the Labia or Private Parts
L
L
L
L
L
L
Page 1 of 6
Both
Both
Both
Both
Both
Both
Do you experience in your legs or ankles?
Symptom
Pain
Aching
Tenderness
Cramping
Tired/Heavy Sensation
Itching
Restless Legs
Bleeding from Veins
Skin Ulcers or Sores
Swelling
Please check all that apply and at what level.
Mild
Moderate
Severe
Highest Level on Leg?______________________________________________________
List what kind of work you do and describe your work activities:
Sit
Stand
Work
hours/day
hours/day
hours/day
Have you missed work due to your vein problems? Y N
Have you ever had any of the following:
Injury requiring surgery to the leg or casting?
Blood clot in the Deep Veins (DVT)?
Phlebitis (Superficial veins, SVT)?
Venous Stasis Ulcer?
Sclerotherapy?
LASER Treatment of the Legs?
Vein Stripping?
Phlebectomy?
Thermal Ablation? Radiofrequency
LASER
Major Leg Surgery
Location
R
L
R
L
R
L
R
L
R
L
R
L
R
L
R
L
R
L
R
L
(circle)
Both
Both
Both
Both
Both
Both
Both
Both
Both
Both
Many insurance companies require 1-3 months of “conservative, nonoperative treatment” and
significant residual symptoms interfering with the activities of daily living in spite of conservative
treatment in order for the patient to qualify for treatment. Conservative treatment includes mild
exercise, periodic leg evaluation, weight loss, avoidance of prolonged sitting or standing (when feasible),
and compression therapy (support hose).
Page 2 of 6
Please Answer The Following Questions Carefully:
How does your condition limit or change your daily activities? __________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
What do you not do because of your problem? Pain?, Timing of discomfort or swelling?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
What methods have you used to relieve your leg discomfort?
Leg Elevation
Elastic Wraps
Ibuprofen, Motrin, Advil
Exercise
Warm Soaks
Naproxen, Naprosyn, Aleve
Flexion/extension of the ankle
Cold Compresses
Others _________________
Walking
Aspirin
_________________
Support Hose
Tylenol, acetaminophen
(Circle One)
Have you worn elastic support hose? How long?_____months
Y
N
Calf?
Thigh?
Pantyhose?
Compression Rating: <15mm
15-20mm
20-30mm
30-40mm
Have you taken pain medication for your veins? How long?___
If yes, What medication?________________________________
Y
N
Do you elevate your legs for relief?
Hours/Day______
Y
N
Are you on a weight loss routine?
How long?_____ Months
Y
N
Y
N
Do you exercise?
Mild/occasional
Routinely
Intense Exercise
How many children have you carried to delivery?__________
How many stillbirths or spontaneous miscarriages?________
Do you have Pelvic Pain?
Before or during menses
During or shortly after intercourse
How long before pain resolves?____________________________
Do you have bulging or painful varicose veins in the female organs?
Do you have more leg discomfort during or
around your menstrual period?
Are you pregnant or planning pregnancy soon?
Are you breastfeeding currently?
Have you ever been tested for or found positive for a Patent Foramen
Ovale (PFO) or Atrial Septal Defect (ASD)?
Page 3 of 6
Y
N
Y
Y
Y
N
N
N
Y
N
Current Medications: (Include hormone and pain medications)
Drug
Dose
Frequency
Route
(Oral,
Injectable)
Drug Intolerances/Allergies:
Drug
Reaction/Sensitivity
Do you have any allergies to iodine
or shellfish?
Y
N
Do you have problems with tape?
Y
N
What kind?______________________________
Are you latex sensitive?
Y
N
Reaction________________________________
Do you smoke?
Y
N
_____packs/day
Do you consume alcohol?
Y
N
_____drinks/week
Do you consume recreational drugs?
Y
cigarettes
pipe, cigar
N
Type___________________________________
Page 4 of 6
Please list other health problems:
Anemia
Ankle skin changes
Atherosclerosis (hardening of the arteries)
Bleeding/blood disorder
Chest pain discomfort
Constipation
Chrohn’s disease, IBS
Diabetes, insulin dependent
Diabetes, non-insulin dependent
Easy bruising
Heart disease
Hepatitis
PAST SURGICAL HISTORY:
HIV
Hypertension (high blood pressure)
Kidney disease
Leg ulcers
Liver disease
Lupus
Migraine headaches
Migraine with aura
Mitral valve prolapse
Pulmonary embolus
Rupture of a vein
Trauma to legs
Other__________________________________
(List Procedures and dates)
FAMILY MEDICAL HISTORY:
FAMILY HISTORY:
Is there a history in your FAMILY of spider or varicose veins?
Describe which:
Mother____________________
Siblings______________________
Father_____________________
Aunt/Uncle___________________
Grandparents_______________
Child________________________
Is there a history in your FAMILY of deep venous thrombosis, stroke or clotting disorders?
Describe which:
Mother____________________
Siblings______________________
Father_____________________
Aunt/Uncle___________________
Grandparents_______________
Child________________________
Page 5 of 6
Review of Systems:
No
Do you currently have any of the following?
If you check “Yes” for anything, explain on the line below the checkbox.
Yes
Constitutional: (Fevers, chills, recent unexplained loss of appetite or weight).
Eyes: (Any recent unexplained change in visual acuity, double vision, excessive tearing
or crusting).
ENT: (Recent change in hearing ability, discharge, sore throat, dizziness or ringing in
the ears).
Cardiac: ( Chest pain, shortness of breath, waking from sleep breathless, or cardiac
meds).
Respiratory: (Shortness of breath, productive cough, coughing up blood, or pain with
breathing).
Gastrointestinal: (Change in bowel habits, black, red or bloody stools, vomiting or
belly pain).
Genitourinary: (Incontinence, frequent, urgent or painful urination, waking at night to
urinate).
Musculoskeletal: (Change in walking ability or strength. Painful joints).
Skin: (Problematic rashes or itching, changes in skin color or sores that won’t heal).
Neurological: (Unexpected, unexplained numbness, tingling, or loss of memory or
movement).
Psychiatric: (Suicidal thoughts or hallucinations).
__________RN
_________LPN
Stephen F. Daugherty, MD, FACS, RVT, RPhS
Pamela L. Beasley, FNP-BC
Date Reviewed:__________
Patient Health History for an Initial Office Visit
Patient Name:______________________________________
Date:_____________________
Page 6 of 6