Today's Date:
Appointment Time: MorningAfternoonEvening
Phone:
Email:
DOB:
Sex: MaleFemale
Do you have or have you ever been diagnosed with:
Varicose Vein Problems
YesNo
Leg:RL
Phlebitis (vein redness/tenderness)
Blood clots
Deep vein thrombosis (DVT)
Saphenous vein reflux
Do you experience any of the following in your leg(s):
Aching/pain
Heaviness
Tiredness/fatigue
Itching/burning
Swelling
Cramps
Restless Legs
Throbbing
Skin or ulcer problems
Other
Which of the following do you currently do to improve your leg vein symptoms:
Medication for pain
What?
Elevation of legs
Wear support hose
Have any of your family members had:
Varicose veins
Vein Stripping
Blood coagulation disorder
Stroke, heart attacks or pulmonary emboli
Have you ever been treated for varicose veins with:
Sclerotherapy
Laser therapy (spider veins)
Phlebectomy
Vein stripping surgery
RF ablation (VNUS Closure)®
Does your work require:
Prolonged standing periods?
Prolonged sitting periods?
Do you exercise regularly?
Do you smoke?
Pregnancies?
How many?
