Confidential Health and History Form
TODAY’S DATE: ________________________________________
Patient Name: ____________________________ Date of Birth: ______Age:________
Sex: ____Height:_______Weight:_______Primary Care Physician____________________
How did you hear about us?__________________________________________________
Allergies:_______________________________________________________________
Please List ALL medications include the dosages and how often you take them.
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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? _____________________
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Family Vein History
Does anyone in your family have (or did have) varicose veins, spider veins, leg ulcers or swollen legs?
Father
Mother
Brother(s)
Sister(s)
Other _________________
Yes
Yes
Yes
Yes
No
No
No
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 in recent months?
Yes
No
Describe: ________________________________________________________________
Do you take any medication for pain or discomfort in your legs? (i.e., Advil, Motrin)
Yes
No
If yes, what medication do you take and how many times/mgs per day? ________________
________________________________________________________________________
Do you elevate your legs to relieve discomfort?
Yes
No
If yes, how long per day do you elevate and does it provide relief? ______________________
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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?
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Do you wear medical grade compression stockings?
Yes
No
If yes, what type and gradient? How long have you worn them?____________________
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If yes, what is the name of the physician who prescribed your compression stockings and
when were they prescribed? ___________________________________________________
Do you wear light support hose (i.e., Sheer Energy)?
If yes, do they provide relief?
Yes
Yes
No
No
What type of work do you do? ______________________________________________________
How long 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
Do you have a history of?
___Anemia
___Atherosclerosis
___Ankle skin changes
___Bleeding/Blood disorder
___Cancer
___Chest pain or discomfort
___Crohn’s disease/IBS
___Constipation
___Deep Vein Thrombosis/Clot
___Diabetes
___Easy bruising
___Hepatitis
___HIV
___Other__________________________
___Hypertension
___Kidney disease
___Leg ulcers
___Liver disease
___Lupus
___Migraine headaches
___Myocardial Infarction
___Mitral Valve Prolapse
___Pulmonary Embolus
___Rupture of a vein
___Superficial Thrombophlebitis
___Trauma to your legs
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 venous thrombosis, stroke, clotting disorders or heart
disease?
___Mom _______________________
___Siblings _______________________
___Dad ________________________
___Aunt/Uncle ____________________
___Grandparents _________________
___Child _________________________
Social History
Who do you live with? __________________ What do/did 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 your ever smoke? _______ When did you quit? _____________________________
Review of Systems
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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