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James St. George, M.D.
Felipe Collares, M.D.
Eugenio Concepcion, D.O.
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Submit Patient Information
Submit Patient Information
Confidential Health History
Patient Information
Name
*
First
Middle
Last
Date
*
Date Format: MM slash DD slash YYYY
DOB
*
Referring Doctor
Reason For Visit
*
Symptoms
Do your legs, ankles or feet experience:
*
Aching / Discomfort
Cramping
Itching
Tingling
Restless Leg(s)
Swelling
Tired / Heavy
Burning
Numbness
Other
None
Check any methods you have used
*
Warm Soaks
Exercise
Pain Meds
Wraps
Compression Stockings
Leg Elevation
Cold Packs
Aspirin
Walking
Tylenol
Ibuprofen
Flexion / Extension of your feet
None
Other Methods Used
Are you on your feet for long periods?
*
Yes
No
In what capacity?
Vein History
Is there a history in your FAMILY of spider or varicose veins?
*
Yes
No
If so, please check and describe
Mother
Father
Siblings
Grandparents
Please describe
Have you ever had a blood clot anywhere in your body?
*
Yes
No
Please describe
Is there a family history of blood clots (DVT), pulmonary embolism or clotting disorders??
*
Yes
No
BLEEDING HISTORY
Bleeding History (check all that apply)
*
Aspirin Use
Coumadin or "blood thinner"
Plavix
None
Have you received blood-thinning medications such as heparin or lovanox before or after procedure?
*
Yes
No
Do you take antibiotics before dental or invasive procedures?
*
Yes
No
Do you take iron pills or vitamins that contain iron?
*
Yes
No
Do you have a communicable disease such as HIV or hepatitis?
*
Yes
No
Do you have a hole in your heart such as Patent Foramen Ovale (PFO) or Atrial Septal Defect (ASD)?
*
Yes
No
Do you have any allergies or sensitivities to medicine or tape?
*
Yes
No
Please describe
MEDICATIONS (Please list all medications, dose and reason)
MEDICAL HISTORY (Please list ALL past or present medical problems)
PAST SURGICAL HISTORY (Please list ALL past surgeries and include year of procedure)
SOCIAL HISTORY
Do you smoke?
*
Yes
No
How many packs per day?
How many years? If you quit, what year?
Tell us what kind of work you do or if you are retired
*
Marital Status
*
Married
Single
Divorced
Widowed
Number of Pregnancies
Have you ever had a miscarriage?
Yes
No
DRUG ALLERGIES
Do you have any known drug allergies to any of the following? (Please check all that apply)
*
Lidocaine
Epinephrine
Sodium Bicarbonate
Heparin
Valium
Vicoden
Percocet
Penicillin / Antibiotics
Nitroglycerin
Latex
Iodine
NONE
Do you have any other known drug allergies? (Please list)
REVIEW OF SYSTEMS (Please check all that apply)
Constitution
Weight Loss
Weight Gain
Night Sweats
Fever
Skin
Change in size/color of moles
Rash
Bruising
Eyes
Decreased Vision
Double Vision
Blurred Vision
Glasses
ENMT
Pain Deafness
Discharge
Ringing in ears
Sinus Drainage
Nose Bleed
Hoarseness
Cardiac
Palpitations
Chest pain
Shortness of breath
Fatigue
Swelling in feet/legs
Respiratory
Cough
Production of sputum
Coughing of blood
Pain
Gastro
Painful Swallowing
Nausea
Vomiting
Vomit Blood
Indigestion
Diarrhea
Constipation
Tarry Stools
Yellow Jaundice
Bloody Stools
Change in BMs
Genito
Kidney / Bladder disease
Decreased urine stream
Unable to urinate
Painful urination
Blood in urine
Musc / Skel
Weakness Trauma
Limited Motion
Bone / Joint Deformity
Neuro
Paralysis
Weakness
Seizure
Fainting
Headache
Migraine
Migraine with Aura
Numbness/tingling in extremities
Head trauma
Psych
Anxiety / Depression
Hallucinations
Endochrine
Change of appetite
Excessive thirst/urination
Goiter
Hematology
Swollen lymph nodes
Bleeding disorders
Immuno
Immune Disorders
Immunosuppressant
Name
This field is for validation purposes and should be left unchanged.