Ballantyne Medical One
15825 Ballantyne Medical Pl. Ste. 240 Charlotte, NC 28277
704-544-5245 / Fax 704 - 544- 5250
Gaston Professional Center
2555 Court Dr., Ste 440, Gastonia, NC 28054
704-861-2072 / Fax 704-854-3996
www.veinscarolina.com
PATIENT NAME:______________________
CHART NUMBER:____________
DATE:___________
Primary care doctor: _____________________ Referred by:_________________________
In just a few words, what is the main problem with your legs/veins?
________________________________________________________________________
Circle ALL of the following symptoms that you experience.
Pain
aching
Restlessness
heaviness
throbbing
tiredness
numbness
weeping fluid bleeding from veins
Circle which leg?
Both Right
fatigue
itching
burning
Stinging
stabbing swelling skin discoloration cramping
sores or wounds on your legs that won’t heal normally
Left
Circle how bad it gets on a scale of 0 to 10 (0=no symptoms 10=worst imaginable)
Right
0
1
2
3
4
5
6
7
8
Left
0
1
2
3
4
5
6
7
8
Circle how long the symptoms have been going on?
< 6 months,
> 6 months,
more than a year,
more than 10 yrs, decades
9
9
10
10
more than 5 years,
Circle everything that makes the symptoms get worse?
Standing sitting
walking
lying down
elevating legs/feet
Other___________________________________________________________________
Describe how these symptoms bother you at work or interfere with your job duties?
________________________________________________________________________
Circle the times when your legs hurt, annoy, bother, distract, disrupt, disturb or decrease your quality
of life:
Showering brushing teeth shaving putting on make-up fixing hair vacuuming dusting
mopping
trash
washing dishes
getting the mail
standing in line
cooking
walking the dog
doing laundry
shopping
washing car cutting grass raking
playing with children or grandchildren
sitting through sporting events
ironing
folding clothes
grocery shopping
trimming bushes
Sitting through church service
Going out to dinner
taking out
gardening
sweeping
sitting at the movies
driving or riding in a car or plane
MD Signature_______________________________
Date______________________
Ballantyne Medical One
15825 Ballantyne Medical Pl. Ste. 240 Charlotte, NC 28277
704-544-5245 / Fax 704 - 544- 5250
Gaston Professional Center
2555 Court Dr., Ste 440, Gastonia, NC 28054
704-861-2072 / Fax 704-854-3996
www.veinscarolina.com
Check EVERYTHING you do to help relieve the symptoms?
_____ Sit down ___ lie down ____ elevate your legs
How often? ____once/day
____more than twice a day
_____Take over the counter medications like Tylenol, Advil, or Aleve
How often? ____ Less than 5 times in 2 weeks
____ more than 5 times in 2 weeks
_____Take prescription :___Pain meds
___muscle relaxants
_____Use a heating pad ____Use ice packs
___restless leg meds ___ arthritis
_____Use creams or ointments like Ben-Gay, Icy Hot?
_____Wear graduated compression garments? ____ less than 3 months
If yes, did they help?
______yes
_______No
____more than 3 months
Check any of the following problems a doctor has diagnosed you with.
_____Deep vein thrombosis (DVT) - blood clot in deep veins of legs (usually treated with blood thinner)
_____Superficial thrombophlebitis- blood clot in superficial veins of leg
_____Pulmonary Embolus (PE)- blood clot that moved to or found in the lung
_____A blood clotting problem (like Antithrombin III, Protein C, Protein S deficiency, Factor V mutation,
Lupus Anticoagulant)
_____A bleeding problem (like Hemophilia, Von Willebran’s, Factor VIII deficiency)
_____Congestive heart failure, ____ kidney failure, ____ Liver cirrhosis ____hypothyroidism
Check prior vein treatments or vein surgery you have had?
____None
_____Vein Stripping, _____Ambulatory Phlebectomy, _____Sclerotherapy, _____Closure, _____EVLT,
_____Leg vein removal for heart or vascular bypass
Who?________________________________ Where?_____________________________________
What other medical problems do you have?
___________________________________
___________________________________
___________________________________
What other operations have you had?
_______________________________________
_______________________________________
_______________________________________
Circle conditions your family members have:
Varicose veins, venous ulcers, DVT, Phlebitis, Pulmonary embolus, clotting or bleeding disorder
What medications, supplements, or vitamins do you take?
______________________________________________________________________________________
______________________________________________________________________________________
___________________________________________________________________________________
Are you allergic to anything?
_____________________________________________________________________________________
Do you use tobacco?
___yes ___no
Do you drink alcohol?
___yes ___no
What Pharmacy do you use?_____________________ __ Phone number:_____________
BP:_____/____ mmHG P:_____bpm HT: _______ WT:_____ lbs SHOE SIZE:_______
MD Signature_______________________________
Date______________________