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Allergies
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Annual Physical Exam
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Anxious
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Asthma
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Attention Problems
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Back Problems
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Broken/ Fractured Bones
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Cold
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Cough
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Depression
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Dizzy
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Earache
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Diabetes
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Diarrhea
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Facial Questions
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Heartburn
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Headache
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Weekly Recur Exam
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Shoulder Pain
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Difficulty Breathing
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Neck Pain
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Difficulty Swallowing
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Wrist Pain
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Difficulty Urinating
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Eye Drainage
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Facial Pain
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Fever
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High Blood Pressure
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Allergies
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Annual Physical Exam
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Anxious
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Asthma
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Attention Problems
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Back Problems
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Broken/ Fractured Bones
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Cold
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Cough
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Depression
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Dizzy
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Earache
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Diabetes
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Diarrhea
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Facial Questions
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Heartburn
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Headache
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Weekly Recur Exam
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Shoulder Pain
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Difficulty Breathing
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Neck Pain
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Difficulty Swallowing
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Wrist Pain
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Difficulty Urinating
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Eye Drainage
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Facial Pain
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Fever
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High Blood
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Occupation
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Referred to our office by
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If Other, please specify
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Primary MD/NP
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OB/GYN
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Podiatrist
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Chiropractor
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Surgeon
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Other MD
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MEDICAL HISTORY
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Are you currently under the care of a physician?
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If Yes for what?
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Have any of the following Medical Conditions?
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If Other, please specify
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Other Health Problems or Medical Conditions
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Surgery (Date,Type,Surgeon)
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Medications (Name,Dose,Frequency)
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Allergies (Medication,Reaction)
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What is your main concern about your leg?
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Does your appearance of your legs bother you?
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When did you first notice vein / other symptoms
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Have / Had below symptoms within the past year
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If Other, please specify
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SEVERITY OF SYMPTOMS
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Vein Disease Risk Factors
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Family History
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If Pregnancies, please mentione the #
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What Non-invasive remedies have you tried?
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If yes, specify Date(s) and Type of treatment
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Have your vein problems affected the following
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Please describe in detail any of the above
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REVIEW OF SYSTEMS
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General
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Turn on switch, if everything is normal
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General Comments
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Skin
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Turn on switch, if everything is normal
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Skin Comments
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HEENT
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Turn on switch, if everything is normal
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HEENT Comments
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Neck
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Turn on switch, if everything is normal
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Neck Comments
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Breasts
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Turn on switch, if everything is normal
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Breasts Comments
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Cardiovascular
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Turn on switch, if everything is normal
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Cardiovascular Comments
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Respiratory
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Turn on switch, if everything is normal
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Respiratory Comments
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Gastrointestinal
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Turn on switch, if everything is normal
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Gastrointestinal Comments
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Urinary
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Turn on switch, if everything is normal
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Urinary Comments
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Genital (Male)
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Turn on switch, if everything is normal
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Genital (Male) Comments
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Genital (Female)
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Turn on switch, if everything is normal
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Genital (Female) Comments
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Peripheral Vascular
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Peripheral Vascular Comments
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MUSCULOSKELETAL
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Turn on switch, if everything is normal
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MUSCULOSKELETAL Comments
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Neurologic
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Turn on switch, if everything is normal
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Neurologic Comments
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Endocrine
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Turn on switch, if everything is normal
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Endocrine Comments
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Psychiatric
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Turn on switch, if everything is normal
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Psychiatric Comments
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