Name _____________________________________________ Birthdate _______________________ Weight_______________
Vein History
My primary care physician/provider is (first and last name) ____________________________________________
I was referred by
my primary care doctor
another doctor ___________________
self
other
Please check all that apply:
I have
Right Left
Pain in the thigh
Pain in the calf
Pain in the foot
Fatigue in the legs
An ulcer on either leg
Swelling in the legs
Bleeding from the leg
These things worsen my pain
Standing for a long time
Sitting for a long time
These things improve my pain: Right Left
Elevating my legs
Over-the-counter support hose
Prescription support hose
Taking a walk
My leg symptoms include:
Dull ache
Sharp pain
Bursting type pain
Heaviness in the calves
Tiredness in the calves
Please tell us more about your leg symptoms: ____________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
If you have varicose or spider veins, how long have you had them?_____________________________________
Have you ever been treated for leg vein problems? No
Yes By whom?_________________________
Have you ever worn support hose? No
Yes If so, do you wear them currently? No
Yes
Are you seeing us mostly because of symptoms in your legs,
cosmetic concerns, or
both?
Please do not write below this line___________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Initial visit form, revised 7.2012
(Label)
p.2
Vein History Please check if you have any history of:
phlebitis
pulmonary embolus
leg ulcers
more than one miscarriage
treatment with heparin or Coumadin
blood clots
leg or hip fracture
Other Past History Please check any conditions you have now or may have had in the past:
cardiac(see below)
bleeding problems
pacemaker / AICD
asthma
stroke
cancer
thyroid problems
arthritis
diabetes
kidney disease
aneurysm
stomach pains
high blood pressure
emphysema
immunosuppression
tuberculosis
high cholesterol
hepatitis
alcoholism
inpatient psychiatric care
Please describe cardiac problem(s): _____________________________________________________________
Please list any other medical conditions:__________________________________________________________
__________________________________________________________________________________________
Is there any chance that you could be pregnant?
yes
no
Surgical History List any operations you have had along with approximate year: _______________________
__________________________________________________________________________________________
Medications List all medicines you take. Include over-the-counter medicines, vitamins, herbal medicines,
and supplements:
_____________________
_____________________
____________________
____________________
____________________
_____________________
______________________
_____________________
______________________
Preferred pain reliever:__________________________
Drug Allergies List any drug allergies & reaction(s):___________________________________________________________
___________________________________________________________________________________________________________________________
Family History Please check any conditions which your family members have:
varicose veins
easy bleeding
blood clots
diabetes
aneurysm
lung disease
heart disease/heart attack
stroke
other medical problems which run in your family: _________________________________________________
Social History Occupation _________________________________________ Marital status: _____________
Does your job affect your leg symptoms? How? _____________________________________________________
Do you care for children? __________ Please list number of children and ages:____________________________
Do you smoke?
No
Yes Were you ever a smoker?
No
Yes When did you quit? ____________
Do you drink alcohol?
No
Yes If yes, how much and how often? _______________________________
Have you ever been in a high-risk group for HIV/AIDS/hepatitis?
No
Yes
please do not write below this line
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
Patient Label
Initial visit form, revised 7.2012
p. 3
System Review Please check any of the following conditions you may have now or have had in the past:
chest pain
irregular heartbeat
rapid heartbeat
high blood pressure
leg pain/cramps
with walking
fevers
unexplained
weight loss
blood clots
leg wounds / ulcers
blood in stools
vomiting blood
frequent back pain
fibromyalgia
memory loss
frequent anxiety
schizophrenia
hoarseness
loss of hearing
blood in urine
problems breathing
frequent cough
other: ______________
other: ______________
Other: Please describe your expectations for treatment with us:
__________________________________________________________________________________________
__________________________________________________________________________________________
How did you hear about us? ___________________________________________________________________
please do not write below this line
Physical Examination
Varicose veins:
Spider varicosities
Venulectasias
Reticular veins
Bulging tributary varicosities
Large bulging varicosities
Other findings:
Edema
Hyperpigmentation
Lipodermatosclerosis
Healed ulcer(s)
Active ulcer(s)
Obesity
Dimished/absent pedal pulses
__________________________
Right
__________________
__________________
__________________
__________________
__________________
Left
__________________
__________________
__________________
__________________
__________________
CEAP
I
__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
III
IV
II
V
VI
Discussed, in terms the patient could understand, the risks and benefits of EVLT laser treatment, including but not limited to infection,
bleeding, swelling, bruising, blood clots, skin burns, scarring, nerve damage, pain, skin color changes, and other risks, including rare serious
complications.
Discussed, in terms the patient could understand, the risks and benefits of microphlebectomy, including but not limited to infection,
bleeding, nerve damage, pain, skin color changes, and other risks. The patient understands that some scarring usually occurs even with
minimally invasive techniques.
Discussed, in terms the patient could understand, the risks and benefits of sclerotherapy, including but not limited to ulceration, skin color
changes (skin staining), matting, deep vein thrombosis, and other risks including rare reports of serious complications. The patient understands
that sclerotherapy agents are often used in an “off-label” manner.
The patient understands that varicose vein disease tends to progress over time, and cannot usually be permanently “cured”. The patient is aware that
multiple treatments may be required to achieve desired results, and that while improvement in symptoms and appearance is common, it is not guaranteed.
For diagnosis, recommendation, and treatment plan, see face sheet.
Physician: ______________________________________
Initial visit form, revised 7.2012
Patient Label
Initial visit form, revised 7.2012