Vein Center Of The South Patient History Form Page 2

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SURGERIES
Please list your past surgeries
________________________________________________________________________
________________________________________________________________________
_______________________________________________________________________
Allergies
□Yes □No
Are you allergic to Latex?
□Yes □No
Are you allergic to any other drugs?
Please list:
________________________________________________________________________
ALL Medications and dosages
Please list: ______________________________________________________________
________________________________________________________________________
_________________________________________________________________________________
_______________________________________________________________
VEIN HISTORY
Have you ever seen any other doctors for treatment of you veins? □Yes □No
If yes, please explain: ______________________________________________________
□Yes □No
Do you or have you ever worn compression stockings?
If yes, how long? _______________________ If yes, what type do you use? __________
□Yes □No
Did they help?
□Yes □No
Have you ever had a blood clot in your leg?
If yes, please give details as to when and which leg: ______________________________
________________________________________________________________________
Do you experience any of the following in your legs?
□Yes □No
□Yes □No
Aching / Pain
Swollen Ankles
□Yes □No
□Yes □No
Heaviness
Leg Cramps
□Yes □No
□Yes □No
Tiredness / Fatigue
Throbbing
□Yes □No
□Yes □No
Itching / Burning
Restless Legs
Any other leg symptoms not listed above? _____________________________________
Do you have problems walking? □Yes □No
If yes, please explain: ______________________________________________________
Are your symptoms worse at the end of the day? □Yes □No
Are the problems you are having in you legs interfering with your lifestyle? □Yes □No
Patient Signature: ___________________________________
Date: _____________

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