Patient Intake Form - Venous History

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Patient Intake Form –Venous History
Patient Name: _________________________ Date of Birth ___________ Referred by: ____________________
Address:
_________________________ City/State _______________________ Zip ____________
Gender: M___ F___ Marital Status ____________
**Email Address: ___________________________________________
Race: American Indian____, Asian____, Black/African American ____, Hawaiian/Pacific Islander____, White _____
Ethnicity: Hispanic _____, Non-Hispanic _____
Smoking Status: Daily _____ Some______ Former_____ Never______
Environmental Allergies: _____________________________________________________________________
Medication Allergies: _______________________________________________________________________
PRIMARY CARE PHYSICIAN: ______________________________________________________________
Medications currently taking:
Medication _____________________ Dosage______ Frequency________ Prescribed by ___________________
Medication _____________________ Dosage______ Frequency________ Prescribed by ___________________
Medication _____________________ Dosage______ Frequency________ Prescribed by ___________________
Medication _____________________ Dosage______ Frequency________ Prescribed by ___________________
Medication _____________________ Dosage______ Frequency________ Prescribed by ___________________
Medication _____________________ Dosage______ Frequency________ Prescribed by ___________________
Medication _____________________ Dosage______ Frequency________ Prescribed by ___________________
Medication _____________________ Dosage______ Frequency________ Prescribed by ___________________
Medication _____________________ Dosage______ Frequency________ Prescribed by ___________________
Medication _____________________ Dosage______ Frequency________ Prescribed by ___________________
Medication _____________________ Dosage______ Frequency________ Prescribed by ___________________
Preferred Pharmacy: __________________________
Please indicate in which leg you have the following symptoms:
Left Leg
Right Leg
Edema (swelling) . . . . . . . . . . . . . . . . . . ___ _____________________
___ ______________________
Pain location . . . . . . . . . . . . . . . . . . . . . . ___ _____________________
___ ______________________
Tiredness/Heaviness . . . . . . . . . . . . . . . . ___ _____________________
___ ______________________
Ulceration . . . . . . . . . . . . . . . . . . . . . . . . ___ _____________________
___ ______________________
Skin Color Changes . . . . . . . . . . . . . . . . ___ _____________________
___ ______________________
Spider Veins . . . . . . . . . . . . . . . . . . . . . . ___ _____________________
___ ______________________
Varicose Veins . . . . . . . . . . . . . . . . . . . . ___ _____________________
___ ______________________
Spontaneous bleeding from veins . . . . . ___ _____________________
___ _______________________
1. Please list activities limited by your condition ___________________________________
________________________________________________________________________
________________________________________________________________________
2. How long have you had venous symptoms? _____________________________________
Circle One
3. Have you had any prior treatment for varicose veins? . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
If yes, dates of treatment ____________________________________________

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