Patient Intake Form - Venous History (Page 3 of 3) in pdf

Patient Name: _________________________

Date of Birth ___________

***********************The following will be filled out by Legacy personnel*****************************

Height_____ Weight ______ Blood Pressure _____/______

Left Leg

Right Leg

Pedal Pulses . . . . . . . . . . . . . . . . . . . . . . ___ _____________________

___ ______________________

Full directions given re: Class II Thigh Hose ________ Fish Oil & Blood Thinners _________

CEAP Classification:

____C0---No visible or palpable signs of venous disease

____C1---Telangiectasies or reticular veins

____C2---Varicose veins; distinguished from reticular veins by a diameter of 3mm or more.

____C3---Edema

____C4a-Changes in skin and subcutaneous tissues secondary to CVD—Pigmentation or eczema

____C4b-Changes in skin and subcutaneous tissues secondary to CVD—Lipodermatosclerosis or atrophic blanche

____C5---Healed venous ulcer

____C6---Active venous ulcer

____S ----Symptoms including ache, pain, tightness, skin irritation, heaviness, muscle cramps, & other venous dysfunction

____A ----Asymptomatic

CEAP Score = _________

_____________________________________________________________________________________________

Attribute

Absent = 0

Mild = 1

Moderate = 2

Severe = 3

____Pain

None

Occasional, not restricting

Daily, moderate activity limitation,

Daily, severe, limiting activities

activity or requiring analgesics

occasional analgesics

or requiring regular analgesic

use

____Varicose veins

None

Few, scattered: branch VVs

Multiple: GS varicose veins confined

Extensive: thigh and calf, or GS

to calf or thigh

and LS distribution

____Venous edema

None

Evening ankle edema only

Afternoon edema, above ankle

Morning edema above ankle and

requiring activity change,

elevation

____Skin

None or focal

Diffuse but limited in area and

Diffuse over most of gaiter

Wider distribution (above lower

pigmentation

low intensity

old (brown)

distribution (lower third) or recent

third) and recent pigmentation

(tan)

pigmentation (purple)

____Inflammation

None

Mild cellulitis, limited to

Moderate cellulitis, involves most of

Severe cellulitis (lower third and

marginal area around ulcer

gaiter area (lower third)

above) or significant venous

eczema

____Induration

None

Focal, circummalleolar (< 5

Medial or lateral, less than lower third

Entire lower third of leg or more

cm)

of leg

____No. of active

> 2

ulcers

____Active ulceration,

None

< 3 months

> 3 months, < 1 year

Not healed > 1 year

duration

____Active ulcer, size None

< 2 cm diameter

2–6 cm diameter

> 6 cm diameter

____Compressive

Not used or not

Intermittent use of stockings

Wears elastic stockings most days

Full compliance: stockings and

therapy

compliant

elevation

________________________________________________________________________________________________

____ TOTAL (max 30 pts) Venous Clinical Severity Score

Education Materials Provided: _____ Brochure _____ Website _____Drug Education _____

Portal Access Provided: _____

Nurse Signature _______________________________ Date ___________________

Patient Intake Form - Venous History Page 3

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