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CHIEF COMPLAINT
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Patient presents with complaints of what extremities?
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PHYSICAL ASSESSMENT
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Persisting complaints and symptoms
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Severity of discomfort
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APPEARANCE
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Level of distress
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Ambulation
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Lower Extremities
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RLE
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LLE
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QUALITY OF LIFE ASSESSMENT
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Do symptoms affect patient daily?
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Is patients quality of life or ability to perform daily activities affected?
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CONSERVATIVE TREATMENT & HISTORY
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Duration of symptoms? (Number)
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Weeks / Months / Years
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Conservative Management Attempted by Patient
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Duration of conservative management? (Number)
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Weeks / Months / Years
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Has patient improved with conservative treatment?
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SUPPORTING DIAGNOSTIC EVALUATION
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Has patient had an ultrasound?
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Ultrasound Report
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Ultrasound Report
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CLINICAL VENOUS SCORES
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CEAP Score
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Venous Disability Score VDS
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PATIENT DIAGNOSIS
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Patient diagnosis codes
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HPI Note
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TREATMENT PLAN & PATIENT EDUCATION
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Treatment plan discussed
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RFA UNITS RIGHT
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RFA UNITS LEFT
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VARITHENA UNITS RIGHT
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VARITHENA UNITS LEFT
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