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

Email

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Patient Information

Symptoms

Vein History

BLEEDING HISTORY

SOCIAL HISTORY

DRUG ALLERGIES

REVIEW OF SYSTEMS (Please check all that apply)