PATIENT NAME:______________________ D.O.B.:________________ 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 in your LEGS.
Pain Aching Heaviness Tiredness Fatigue Itching Burning Stinging Restlessness
Throbbing Numbness Stabbing Swelling Skin Discoloration Cramping weeping fluid
Bleeding from veins Sores or Wounds on your legs that won’t heal normally
Circle which leg? Both Right 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 9 10
Left 0 1 2 3 4 5 6 7 8 9 10
Circle how long the symptoms have been going on?
A few days a few weeks a few months > 6 months, more than a year,
more than 5 years, more than 10 yrs decades
Circle everything that makes the symptoms get worse?
Standing sitting walking lying down elevating legs/feet
Other___________________________________________________________________
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 Cooking Washing Dishes Doing Laundry Folding Clothes Ironing
Taking out trash Getting the mail Walking the dog Playing with Children or Grandchildren
Gardening Cutting grass Raking Trimming bushes Sweeping
Standing in line Shopping Grocery shopping Washing car Hiking Biking Tennis Golf Hunting
Sitting through church service Sitting at the Movies Sitting through Sporting Events
Driving or riding in a car or plane
Check EVERYTHING you do to help relieve the symptoms?
_____ Sit down ___ lie down ____ elevate your legs
_____Take over the counter medications like Tylenol, Advil, or Aleve
_____Take prescription: ___Pain meds ___muscle relaxants ___restless leg meds ___ arthritis meds
_____Use a heating pad ____Use ice packs _____Use creams or ointments like Ben-Gay, Icy Hot?
_____Wear graduated compression garments? How long? ____________
If yes, did they help? ______yes _______No Who Recommended them? _____________
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
Other: Do you have pain over the left kidney area? Y N
Do you have blood in the urine for unknown reason? Y N
Ladies Only: Do you have varicose veins in the “private” Areas? Y N
Do you have unexplained pelvic or lower abdominal pain? Y N
Do you have pain DURING intercourse? Y N
Do you have Pain AFTER Intercourse Y N
Men: Do you have varicose veins on the scrotum, testicle or buttock area Y N
Check prior vein treatments or vein surgery you have had? ____None
_____Vein Stripping (Left, Right, Both) By Whom?__________________ Where?______________
____Closure (Left, Right, Both) By Whom?__________________ Where?______________
_____EVLT (Left, Right, Both) By Whom?__________________ Where?______________
_____Ambulatory Phlebectomy (Left, Right, Both) By Whom?__________________ Where?______________
_____Sclerotherapy (Left, Right, Both) By Whom?__________________ Where?______________
_____Vein removed for bypass (Left, Right, Both) By Whom?__________________ Where?______________
Circle conditions your family members have: and which family member
Varicose Veins Mother Father Sister Brother Aunt Uncle Grandparent
Venous Ulcers Mother Father Sister Brother Aunt Uncle Grandparent
DVT, Phlebitis, Mother Father Sister Brother Aunt Uncle Grandparent
Pulmonary Embolus, Mother Father Sister Brother Aunt Uncle Grandparent
Clotting Disorder Mother Father Sister Brother Aunt Uncle Grandparent
Bleeding Disorder Mother Father Sister Brother Aunt Uncle Grandparent
What other medical problems do you have?
___________________________________ _______________________________________
___________________________________ _______________________________________
___________________________________ _______________________________________
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What operations have you had?
___________________________________ _______________________________________
___________________________________ _______________________________________
___________________________________ _______________________________________
___________________________________ _______________________________________
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What medications, supplements, or vitamins do you take? Include dosage and frequency
___________________________________ _______________________________________
___________________________________ _______________________________________
___________________________________ _______________________________________
___________________________________ _______________________________________
___________________________________ _______________________________________
What are you allergic to? ____________________________________________________________
Circle What Happens? Lips and mouth swell up? Hives or whelps? Itching Nausea? Vomiting? Diarrhea? Other_______________________________
Are you: Single Married Divorced Widowed
How many Children do you have?_____________
What is your occupation?___________________
Do you use tobacco? ___yes ___no
Do you drink alcohol? ___yes ___no
How many times in the past year have you had 5 (for men) or 4 ( for women and all adults over 65) in a day______
Do you take Antabuse
What Pharmacy do you use?_____________________ Pharmacy Phone number:_____________
BP: _________mmHg P:______bpm HT: _______ WT:_____ lbs SHOE SIZE:_______
