|
Venous Health History
|
|
|
Left Leg Symptoms (do you ever have any of these)
• • •
|
Right Leg Symptoms (do you ever have any of these)
• • •
|
|
What is your leg pain level most days?
|
How Many Years have you had symptoms or varicose veins?
|
|
Have you ever had the following?
|
|
|
Vein Stripping or Closure
|
Year (most recent)
|
|
Vein Injections
|
Year (most recent)
|
|
Leg Ulcers
|
Year (most recent)
|
|
Blood Clots
|
Year (most recent)
|
|
Phlebitis or Cellulitis
|
Year (most recent)
|
|
Select all the following that may be limited because of your leg.
|
|
|
Which of these give you trouble because of your legs?
• • •
|
Other/comments (optional)
|
|
Do you have...
|
|
|
Do you or have you worn compression socks before?
|
How long?
|
|
A family history of varicose veins?
|
Who?
• • •
|
|
Worsening leg symptoms in recent months?
|
|
|
Do you take any medication for your legs?
|
What medication?
|
|
Do you elevate your legs?
|
|
|
Do you walk/exercise?
|
|
|
Does your occupation require prolonged standing or sitting?
|
|
|
Medications
|
List Current Medications
|
|
Allergies
|
List Allergies
|
|
Past Medical History
|
List Past Medical History
|
|
Past Surgical History
|
List Past Surgical History
|
|
Review of Systems
|
|
|
***Select Current Medical Problems by holding down the "Control" key if selecting more than 1 in each field***
|
|
|
Gastrointestinal
• • •
|
Hepatic / Renal
• • •
|
|
Mental
• • •
|
Vision
• • •
|
|
Respiratory
• • •
|
Cardiovascular
• • •
|
|
Endocrine
• • •
|
Neurological
• • •
|
|
Musculoskeletal
• • •
|
Skin
• • •
|
|
Social History
|
|
|
Weekly Alcohol Use
|
Smoking Status
|
|
Height (in)
|
Weight (lbs)
|
|
For Women Only
|
Have you ever been Pregnant?
|
|
Number of Pregnancies
|
Number of Live Births
|
|
Are you currently pregnant?
|
Have you breastfed in the the last 6 weeks?
|
