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Reason For Visit
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Referred By
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Chief Complaint
• • •
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Others
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History of Present Illness
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Location
• • •
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Location Comments
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Quality
• • •
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Quality Comments
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Severity
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Severity Comments
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Duration
• • •
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Duration Comments
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Onset / Timing
• • •
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Onset Comments
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Context
• • •
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Context Comments
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Modifying Factors
• • •
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Modifying Factors Comments
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Associated Symptoms
• • •
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Associated Symptoms Comments
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Previous Treatment
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PSFH
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Vein Treatment History
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Medical / Surgical History
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Past Medical History
• • •
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Comments
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Past Surgical History
• • •
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Comments
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Childhood illnesses
• • •
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Comments
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Childhood Immunizations
• • •
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Comments
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Date of last PE
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Family / Social History
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Family History of Varicose Vein
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Comments
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Smoking History
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Comments
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Review of Systems
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Constitutional
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Comments
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Eyes
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Comments
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ENT / Mouth
|
Comments
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Cardiovascular
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Comments
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Respiratory
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Comments
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Gastrointestinal
|
Comments
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Genitourinary (F)
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Comments
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Musculoskeletal
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Comments
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Integumentary
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Comments
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Endocrine
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Comments
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Lower Extremity
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Comments
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Neurological
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Comments
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Psychiatry
|
Comments
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Allergic / Immunologic
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Comments
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LEG MEASUREMENTS
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Calf Circumference Right
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Calf Circumference Left
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Ankle Circumference Right
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Ankle Circumference Left
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PHYSICAL EXAM
|
|
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Constitutional Normal
|
Constitutional Abnormal
• • •
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Constitutional Comments
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HEENT WNL
|
HEENT Abnormal
• • •
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|
HEENT Comments
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|
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Right Lower Extremity Exam
• • •
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Right Lower Ext Comments
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Left Lower Extremity Exam
• • •
|
Left Lower Ext Comments
|
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Abdomen WNL
|
Abdomen Abnormal
• • •
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Abdomen Comments
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|
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MSK WNL
|
MSK Abnormal
• • •
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MSK Comments
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|
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Skin WNL
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Skin Lesion
|
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Skin Comments
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Extremities WNL
|
Extrem Abnormal
• • •
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Extrem Comments
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Neuro WNL
|
Neuro Abnormal
• • •
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Neuro Comments
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CEAP-VCSS
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|
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CEAP Right
• • •
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CEAP Left
• • •
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VCSS Right
• • •
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VCSS Left
• • •
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LIFESTYLE RECOMMENDATIONS
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LifeStyle Recommendations
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Discussions
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Procedure Recommendations / Follow Up
• • •
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Lifestyle Comments
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Free Draw Switch
|
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Anterior Right Leg
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Posterior Right Leg
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Anterior Left Leg
|
Posterior Left Leg
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Picture Right leg
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Picture Left leg
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All sides Leg Diagram
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