Page 1 of 2
(PE Form - HVI Website, Rev.10.31.2012)
PHYSICAL EXAMINATION FORM
Date:_____ / _____ / __________ Patient Name:________________________________________________
Last
DOB:_______□ See above
Ordering Physician:
HVI Clinic:
First
M.I.
Referring Provider: _________________ Referring Clinic:_________________
□ Dr. Peter Benson □ Dr. Carl Dando □ Dr. Roger Hogue □ Dr. Ronald Kolegraff
□ Burnsville □ Duluth □ EP □ Fargo □ MKTO □ MG □ Shorewood □ WBL □ WBRY
VDUS performed by RVT:
□ Benson □ Brantner □ Dando □ Hogue □ Kolegraff □ Mollenkopf □ Rostad
PHYSICAL EXAMINATION
Head & Face:
□ Normal head and face examination
□ Abnormal findings:___________________________________________________________
Neck/Airway:
□ Normal neck examination and patent airway
□ Abnormal findings:___________________________________________________________
Chest/Lungs:
□ Normal respiratory rate, breathing effort, and breath sounds
□ Abnormal findings:___________________________________________________________
Cardiac:
□ Normal heart rate, heart sounds, heart rhythm
□ Abnormal findings:___________________________________________________________
Skin:
□ Normal skin pigmentation, skin turgor, and skin integrity
□ Abnormal findings:___________________________________________________________
Neurologic:
□ Normal motor and sensory examination of lower extremities
□ Abnormal findings:___________________________________________________________
Pulses:
□ Normal pulses of lower extremities
□ Abnormal findings:___________________________________________________________
Veins:
□ Normal surface veins of abdomen, pelvis, and lower extremities
□ Abnormal findings:___________________________________________________________
____________________________________________________________________________
CEAP Class for left leg:
CEAP Class for right leg:
ASx
ASx
Symptomatic
Symptomatic
1
2
1
3
2
4a
3
4a
4b
4b
5
6
5
6
Hogue Vein Institute ● Corporate Office ● 7365 Kirkwood Court N., Ste 120, Maple Grove, MN 55369 ● Office 763.447.2500 ● Fax 763.447.2505
Page 2 of 2
(PE Form - HVI Website, Rev.10.31.2012)
PHYSICAL EXAMINATION FORM
Summary of Venous Duplex Ultrasound Assessment findings:
□ See Venous Duplex Ultrasound Assessment – HVI Form
Right leg: □ See Venous Duplex Ultrasound Assessment Sheet – HVI Form
Left leg:
Vein Health & History Form supports a diagnosis of Symptomatic Venous Disease:
Yes
No
Physical Examination and Venous DUS supports a diagnosis of Symptomatic Venous Disease:
Patient’s vein disease affects the patient’s Activities of Daily Living:
Yes
Yes
No
Patient has failed Conservative Vein Therapy in accordance with his/her Insurance Requirements:
Therapeutic vein care is Medically Indicated:
Yes
No
Yes
No
No
Therapeutic vein care is recommended at Hogue Vein Institute:
Yes
No
Therapeutic vein care treatment plan, options, and treatment alternatives discussed with patient:
Yes
No
Therapeutic vein care recommendations at Hogue Vein Institute based on vein consultation findings:
Left leg:___________________________________________________________________________
__________________________________________________________________________________
Right leg:__________________________________________________________________________
__________________________________________________________________________________
ICD-9 CM Diagnosis Codes: ___________
___________
___________
___________
__________
CPT Code(s) for today’s E&M visit (History & Physical Exam): _______________ (99203 or 99204)
CPT Code(s) for today’s noninvasive testing:
Venous Duplex Ultrasound study: _______________________ (93970-Bilateral or 93971-Unilateral)
Photoplethysmography: _______________________________ (93965-Bilateral)
Rx provided for Class II (30-40 mmHg) thigh high or panty hose GCS:
____________________________________
__________________
RVT Signature
Date
Yes
No
____________________________________
Physician Signature
__________________
Date
Hogue Vein Institute ● Corporate Office ● 7365 Kirkwood Court N., Ste 120, Maple Grove, MN 55369 ● Office 763.447.2500 ● Fax 763.447.2505