Varicose Vein Patient Form

Patient Name: Last______________________, First_______________________ Date:___________________

#Years with Varicose or Spider Veins: ______ Referred by: ________________________________________

Vein/Skin Conditions: Check all that apply.

_ None
_ Purple Vein Networks
_ Small Red Spider Veins
_ Flat, Blue-Green Veins
_ Diagnosed Vein Disease
_ Abdominal Veins
_ Skin discoloration
_ Vaginal Veins
_ Purple Veins
_ Chest or Breast Veins

_
_
_
_

Facial Veins
Ankle Sores
Bulging Veins
Other: _______________

Leg and Ankle Problems: Check all that apply. Please Explain Any Yes Answers
_ Aches
_ Fatigue
_ Cramps
_ Pain
_ Heaviness
_ Restlessness
_ Swelling
_ Itching
_ Other__________________
Explanation(s) ______________________________________________________________________________
Methods Used To Relieve Leg Discomfort: Check all that apply.
_ No Discomfort
_ Warm Soaks
_ Leg Elevation
_ Aspirin Packs
_ Flexion/Extension of Feet
_ Wraps
_ Walking
_ Ibuprofen
Choose one
Do you wear compression stockings? _____________

_
_
_
_

Tylenol
Exercise
Cold
Other _________________

Choose one
If yes, the stockings were bought __________________

Choose one
What type of compression stockings? _____________ Did the stockings resolve your symptoms?____________

Family History Select all family members that have/had these conditions
Spider or Varicose Veins?

_ I Dont Know
_ None
_ Parent

Deep Thrombosis, Stroke, or Clotting Disorder?

_ Child
_ Grandparent
_ Sibling

_ Aunt/Uncle
_ Other

_ I Dont Know
_ None
_ Parent

_ Child
_ Grandparent
_ Sibling

_ Aunt/Uncle
_ Other

Conditions Patient Had / Has:

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_
_
_
_
_
_

None
Anemia
Ankle Skin Changes
Atherosclerosis
Bleeding Blood
Disorder
Chest Pain/Discomfort
Constipation

_
_
_
_
_
_
_
_

Crohns Disease / IBS

Deep Vein Thrombosis
Diabetes with insulin
Diabetes No insulin
Easy Bruising
Heart Disease
Hepatitis
High Cholesterol

_
_
_
_
_
_
_
_

HIV / AIDS
Hypertension
Kidney Disease
Leg Ulcers
Liver Disease
Stroke
Lupus
Migraine Headaches

_
_
_
_
_

Mitral Valve Prolapse

Pulmonary Embolus
Bleeding/Rupture Vein
Superficial
Thrombophlebitis
Trauma to Leg

Current Medical Situation:

Choose one
Do you have any allergy to medications or substances? _____________
Please list________________________

Choose one
Do you have any current illnesses? _____________
If yes, please describe ______________________________

Please list any current medications, vitamins, or herbal supplements that you are taking:
__________________________________________________________________________________________
(Female Patients Only)
Choose one
Choose one
Are you now, or are planning to be pregnant? _____________
Are you currently breast feeding? _____________
Choose one
Do you have discomfort during your menses? _____________

N/A
How many pregnancies have you had? _________

N/A
Miscarriages? _________

Choose One
Live Births? _________

Social History
Occupation: _________________________
Choose one
Do you smoke? _____________

Choose One
How many packs per day? _________

Choose One
Choose one
Do you drink alcohol? _____________
How many drinks per day? _________

Choose one
On your feet for long periods of time? _____________

If yes, please explain____________________________

Choose One
Does walking [increase, decrease, stay the same] discomfort _____________

Past Surgeries Check those that apply and explain

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_
_
_
_
_
_

Surgery

Date

Type of Surgery

Abdominal
Heart
Head/Neck
OB/GYN
Breast
Orthopedic
Other

_______________
_______________
_______________
_______________
_______________
_______________
_______________

___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________

Previous Vein Treatment(s):

Procedure
_ Stab Phlebectomy
_ Varicose Vein Injections
_ Endovenous Laser Ablation
_ Ligation and/or Stripping
_ Radio-Frequency Ablation
_ Spider Vein Injections
_ Spider Vein Laser Therapy

Leg
Choose One
________________
Choose One
________________
Choose
One
________________
Choose One
________________
Choose
One
________________
Choose One
________________
Choose One
________________

Date
________________
________________
________________
________________
________________
________________
________________

Provider
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________

What were the results of the above treatments? __________________________________________________

What would you most like to correct about your legs? _______________________________________________
For Office Use Only
Reviewed by: ______________________________

Date: ____________________