Venous Health History Form
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1
2VENOUS HEALTH HISTORY FORM
Please complete front side (only) of this form.
Name:
DOB:
Sex:
Date:
M
F
PCP Name:
How did you hear about us?
Physician Referral: ______________
Provider:
Buzzas
Van Amburg
Phone Book
TV
Radio
Newspaper
Other ________
I. Vascular History
II. Family History
Do you have or have you ever been diagnosed with:
Have any of your family members had:
Varicose vein problems
Y
N
Leg:
R
L
Varicose veins
Y
N
Who?
Phlebitis (
)
Y
N
Leg:
R
L
Vein stripping
Y
N
Who?
vein redness/tenderness
Blood clots
Y
N
Leg:
R
L
Blood coagulation disorder?
Y
N
Who?
Deep vein thrombosis (DVT)
Y
N
Leg:
R
L
Blood clots
Y
N
Who?
Stroke, heart attacks or
Saphenous vein reflux
Y
N
Leg:
R
L
Y
N
Who?
pulmonary emboli
III. Vein Treatment History
Do you experience any of the following in your leg(s):
Aching/Pain
Y
N
Leg:
R
L
Have you ever been treated for varicose veins with:
Heaviness
Y
N
Leg:
R
L
Sclerotherapy
Y
N
Leg:
R
L
Tiredness/Fatigue
Y
N
Leg:
R
L
Laser therapy (spider veins)
Y
N
Leg:
R
L
Itching/Burning
Y
N
Leg:
R
L
Phlebectomy
Y
N
Leg:
R
L
Swelling
Y
N
Leg:
R
L
Vein stripping surgery
Y
N
Leg:
R
L
®
Cramps
Y
N
Leg:
R
L
RF ablation (VNUS Closure
)
Y
N
Leg:
R
L
Restless legs
Y
N
Leg:
R
L
RF Laser Ablation (EVLT)
Y
N
Leg:
R
L
Throbbing
Y
N
Leg:
R
L
Skin or Ulcer problems
Y
N
Leg:
R
L
Other
Y
N
Leg:
R
L
IV. Personal/Activities List
Do you exercise?
Y
How often? ____________
N
Do you smoke?
Y
# Per day? ____________
N
Pregnancies
Y
How many? ____________
N
Do you do any of the following to improve your leg vein
Prolonged sitting/standing periods
Y
N
symptoms:
Does your work require:
Medication for pain
Y
N
What?
Prolonged standing
Elevation of legs
Y
N
When?
Y How long? __________
N
periods
Wear compression hose
Y
N
When?
Prolonged sitting periods
Y How long? __________
N
How long did you wear them?
Heavy lifting?
Y # lbs? ______________
N
V. Activity restrictions due to leg symptoms:
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