Confidential Physical Examination
Date of Service: ________________________
Patient Name: __________________________
Date of Birth: ______________ Age: ________
Blood Pressure: R________ L________ HR________ RR________ Temp ________ SaO2________
General:
 Obese  Thin  Malnourished  Healthy
Head:
 Atraumatic  Normocephalic
Eyes:  PERRLA  EOM’s intact  Sclera anicteric
ENT:  Pharynx clear  Dentition good
Neck:  Supple  No mass  No JVD  No bruit  Thyroid /trachea midline
Lungs/Chest:  Symmetrical movement w/ breathing  No wheeze  No rub  No rhonchi
Heart:  RRR  Normal S1/S2  No murmur  No rub or gallop
ABD:  Soft  Nontender  No mass  No organomegaly
Lower extremities:
Edema
Telangiectasias
Bulging Varicosities
Corona Phlebectasia
Lipodermatosclerosis
Ulceration
Cellulitis
PT pulse
DP pulse
Other ______________________
Measurements:
Ankle circumference
Calf circumference
Thigh circumference
Height
Right
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Left
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Right ______ cm
Right ______ cm
Right ______ cm
Calf ______ cm
Thigh ______cm
Both
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Left ______ cm
Left ______ cm
Left ______ cm
Labs: ______________________________________________________________________________________________________________________
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Diagnostic Test:______________________________________________________________________________________________________________
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Impression: _________________________________________________________________________________________________________________
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Plan:_______________________________________________________________________________________________________________________
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Physician Signature: ____________________________
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Confidential Health and History Form
Today’s Date: __________________________
Phone: ________________________________
Patient Name: __________________________
Date of Birth: ______________ Age: ________
Sex: ____ Height: _____ Weight: _____ Primary Care Physician: ____________________________
How did you hear about us? __________________________________________________________
Please List ALL medications, include the dosage and how often you take them:
Name the Drug
Strength
Frequency Taken
Allergies to medications
Name the Drug
Reaction You Had
Please answer the following questions. Provide estimates for date of occurrence.
Past Venous History
Have you ever had vein stripping surgery?
Yes
No
If yes, when and which leg? ______________________________________________________________________________________________
Have you ever had vein injections?
Yes
No
If yes, which leg and where on the leg? ____________________________________________________________________________________
Have you ever had a blood clot?
Yes
No
If yes, where and when? ________________________________________________________________________________________________
Have you ever had phlebitis?
Yes
No
If yes, which leg and when? ______________________________________________________________________________________________
Have you ever had any test(s) done on your veins?
Yes
No
If yes, when and what type of test and where on the leg? ______________________________________________________________________
Family Vein History
Does anyone in your family have (or did have) varicose veins, spider veins, leg ulcers or swollen legs?
Father
Yes
No
Mother
Yes
No
Brother(s)
Yes
No
Sister(s)
Yes
No
Other ___________________________________
Yes
No
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Symptoms
Do you experience any of the following in your legs?
Aching / pain?
Yes
No
Heaviness?
Yes
No
Tiredness / fatigue?
Yes
No
Itching / burning?
Yes
No
Swollen ankles?
Yes
No
Leg cramps?
Yes
No
Restless legs?
Yes
No
Throbbing?
Yes
No
Other? _________________________________________________________________________________________________________
Have your veins gotten worse
Yes
No
Yes
No
Describe: _____________________________________________________________________________________
Do you take any medication for pain or discomfort in your legs? ( i.e., Advil , Motrin)
If yes, what medication do you take and how many times / mgs per day? __________________________________________________
Do you elevate your legs to relieve your leg discomfort?
Yes
No
If yes, how long per day do you elevate and does it provide relief? ________________________________________________________
Does walking / exercise relieve your leg discomfort?
Yes
No
Does walking / exercise make your leg discomfort worse?
Yes
No
Do you exercise?
Yes
No
If yes, what kind of exercise and how often? ____________________________________________________________________
Do you wear medical grade 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? ________________________________________
When were they prescribed? _______________________________________________________________________________________
Do you wear light support hose (i.e., Sheer Energy)?
If yes, do they provide relief?
Yes
No
Yes
No
What type of work do you do? _______________________________________________________________________________________________
How often do you stand (hours per day) at work? __________
at home? _________
Please be specific and describe how your symptoms are interfering with your activities of daily living: _________________________________________
___________________________________________________________________________________________________________________________
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Past Medical History
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Do you have a history of?
Anemia
Hypertension
Atherosclerosis
Kidney Disease
Ankle skin changes
Leg Ulcers
Bleeding / blood disorder
Liver disease
Cancer
Lupus
Chest pain or discomfort
Migraine headaches
Crohn’s disease / IBS
Myocardial Infarction
Constipation
Mitral Valve Prolapse
Deep Vein Thrombosis / Clot
Pulmonary Embolus
Diabetes
Rupture of a vein
Easy bruising
Superficial Thrombophlebitis
Hepatitis
Trauma to your legs
HIV
Other ______________________________________________________________________
Please list any surgeries or injuries you have had: __________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
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Family History
Is there a history in your family of venous disease, deep vein thrombosis, stroke, clotting disorders or heart disease?
Mother
Father
Grandparents
Siblings
Aunt / Uncle
Child
Social History
Who do you live with? ____________________
What do you do for a living? ________________________________________________________________________________________________
Activity level? ______ Very active
______Some activity
______ Sedentary
Do you smoke? ___ yes ___ no
If yes, how much? ___________ For how long? __
If no, did you ever smoke? _____When did you quit? ______
Review of Symptoms
Are you currently experiencing or recently experienced any of the following? Please mark yes or no.
Cardiovascular: Yes
Pulmonary:
No
Chest pain, pressure
Tightness or heaviness in your chest
Any of the above with exertion
Irregular heart beat
High cholesterol
Shortness of breath
Coughing up blood
Asthma or tuberculosis
Pneumonia or pleurisy
Cough
Patient Signature: _______________________________________________________________ Date: ____________________________________
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