Name: _______________________________________________________ Date: ___________________
Reason for visit (Chief Complaint) _________________________________________________________
Have you ever been treated for this problem: Yes / No, if yes when, and by whom:
______________________________________________________________________________________
Treatments received: Sclerotherapy / Surgery / Laser / Closure / Compression Hose
Circle any signs or symptoms you are experiencing in you legs:
Swelling / Numbness / Tingling / Burning Sensation / Discoloration / Skin breakdown / Ulcer
Pain / Heaviness / Cramping / Restless Legs / Throbbing
How long have you had this problem? ______________________________________________________
Does walking or exercise relieve or aggravate your symptoms? (Circle One)
How has this affected your daily routine? ____________________________________________________
Do you have a personal history of any of the following (Please Circle:)
Asthma
Rheumatic fever
Seizures
Hepatitis
Thyroid
Phlebitis
Pulmonary embolism
Leg Ulcer
Heart Disease
Cheloid Scarring
Deep vein thrombosis
Bleeding Disorders
High Blood Pressure
Problems with anesthesia
Leg fracture or trauma
Autoimmune disease (Lupus)
HIV Blood transfusions Diabetes Cholesterol
Is there a family history of: Varicose Veins / Diseases of the Blood / Phlebitis / Blood clots
List all past surgical procedures: ___________________________________________________________
______________________________________________________________________________________
List all medications you are currently taking: (including any vitamins or herbal supplements)___________
______________________________________________________________________________________
______________________________________________________________________________________
List any known drug allergies: _____________________________________________________________
What type of exercise do you do, and how often? _____________________________________________
Number of past pregnancies: _________ Number of Children: ___________
Current Weight: ______________ Height: _______________
Is there any other information you would consider pertinent to your treatment? ______________________
______________________________________________________________________________________
______________________________________________________________________________________
Signature: ___________________________________________ Date: ______________________