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Chief Compliant
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(1st procedure MACRO or HPI Macro)
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What leg did you do a procedure on?
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Right Leg
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Left Leg
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What type of procedure did you do on the left leg?
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What type of procedure did you do on the right leg?
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RF (right)
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RF (left)
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Varithena (right)
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Varithena (left)
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Sclero (right)
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Sclero (left)
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Phlebectomy (right)
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Phlebectomy (left)
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EVLT Perforator (right)
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EVLT Perforator (left)
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Where was the RF right leg procedure done?
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Where was the RF left leg procedure done?
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Right RFA Location
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Left RFA Location
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Where was the Varithena right leg procedure done?
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Where was the Varithena left leg procedure done?
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Varithena Location (right) (Select 3+)
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Varithena Location (left) (Select 3+)
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Where was the Phlebectomy right leg procedure done?
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Where was the Phlebectomy left leg procedure done?
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Phlebectomy Location (right) (Select 3+)
• • •
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Phlebectomy Location (left) (Select 3+)
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Where was the Sclero right leg procedure done?
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Where was the Sclero left leg procedure done?
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WITH ultrasound - right sclero
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WITH Ultrasound - left sclero.
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Sclero Location (right) (Select 3+)
• • •
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Sclero Location (left) (Select 3+)
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WITHOUT ultrasound - Right Sclero
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WITHOUT ultrasound - Left Sclero
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Sclero Location (right) (Select 3+)
• • •
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Sclero Location (left) (Select 3+)
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Where was the EVLT right leg procedure done?
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Where was the EVLT left leg procedure done?
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EVLT Location (right) (Select 2+)
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EVLT Location (left) (Select 2+)
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Was there a follow ultrasound performed? Turn on if "YES".
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Follow Up Ultrasound? (No Clot)
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Follow Up Ultrasound? (Blood Clot)
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What leg was the follow ultrasound on? (Typically opposite leg of procedure)
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Right Leg
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Left Leg
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FU Ultrasound Location (right) (Select As Needed)
• • •
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FU Ultrasound Location (left) (Select As Needed)
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Additional Reflux? (Leave blank if none) or use for DVT FU.
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Additional Reflux? (Leave blank if none) or use for DVT FU.
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What leg was the blood clot on? (Typically opposite leg of procedure)
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Right Leg (Blood Clot)
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Left Leg (Blood Clot)
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FU Ultrasound Location (right) (Select As Needed)
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FU Ultrasound Location (left) (Select As Needed)
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Size of Clot
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Size of Clot
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Treatment / Blood Thinner / FU / Additional Info
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Treatment / Blood Thinner / FU / Additional Info
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Individuals responsible for chart:
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Additional info. (optional free write sign off)
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Nima Sign off
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Stephanie Morgando, FNP-BC sign off
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Dr. Lomo sign off jointly w/ Nima
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Sabrina Durazo, RVS
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Stella Bitzaya
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Andres sign off
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(Optional) Does the patient need a lymphedema pump request?
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Lymphedema Pump Request
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