MEDICAL HISTORY

 

 

 

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?

___________________________________                     _______________________________________

___________________________________                     _______________________________________

___________________________________                     _______________________________________

___________________________________                     _______________________________________

___________________________________                     _______________________________________

 

 

What operations have you had?  

 

___________________________________                     _______________________________________

___________________________________                     _______________________________________

___________________________________                     _______________________________________

___________________________________                     _______________________________________

___________________________________                     _______________________________________

 

 

 

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:_______

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