Patient Information

Name*

First Middle Last

Date*

DOB*

Referring Doctor

Reason For Visit*

Symptoms

Do your legs, ankles or feet experience:*

Check any methods you have used*

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)*

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

Cardiac

Respiratory

Cough
Production of sputum
Coughing of blood
Pain

Gastro

Genito

Musc / Skel

Weakness Trauma
Limited Motion
Bone / Joint Deformity

Neuro

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.

Submit Patient Information

Patient Information

Symptoms

Vein History

BLEEDING HISTORY

SOCIAL HISTORY

DRUG ALLERGIES

REVIEW OF SYSTEMS (Please check all that apply)