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HISTORY AND PHYSICAL Peachtree Vascular Specialists, P.C. Name:________________________________________________D.O.B.__________________Today's Date______________ Varicose Veins/Spider Veins [ ] Reason for Visit Duration Days [ ] Weeks [ ] Months [ ] Years [ ] Carotid Blockage [ ] Days [ ] Weeks [ ] Months [ ] Years [ ] Stroke [ ] Days [ ] Weeks [ ] Months [ ] Years [ ] Aortic Aneurysm [ ] Days [ ] Weeks [ ] Months [ ] Years [ ] Leg Pains [ ] Days [ ] Weeks [ ] Months [ ] Years [ ] Leg Swelling [ ] Days [ ] Weeks [ ] Months [ ] Years [ ] Ulcer (Non-healing Wounds) [ ] Days [ ] Weeks [ ] Months [ ] Years [ ] DVT (Blood Clots) [ ] Days [ ] Weeks [ ] Months [ ] Years [ ] Dialysis Problems [ ] Days [ ] Weeks [ ] Months [ ] Years [ ] Heavy Prolonged Periods [ ] Days [ ] Weeks [ ] Months [ ] Years [ ] Pain/Pressure Between Hip Bones or in Back of Days [ ] Weeks [ ] Months [ ] Years [ ] Legs [ ] Pain During Sexual Intercourse [ ] Days [ ] Weeks [ ] Months [ ] Years [ ] Other [ ] Days [ ] Weeks [ ] Months [ ] Years [ ] DRUGS AND MEDICATION: List all medications you take, including dosage and how often: Medication Name Dosage (Amount) Frequency (How often) **Do you have any drug allergies? [ ] Yes [ ] No **If so what drug(s) and type of reaction?______________________________________ **Do you have any Anesthesia Complications? [ ] Yes [ ] No **What type?____________________________________________ SURGERIES, HOSPITALIZATIONS & SERIOUS ILLNESSES: List all previous operations, hospital visits & serious illness with reason approximate dates: Past Surgeries Heart Bypass Arterial Bypass Vein Surgeries AV Fistula Access AV Graft Access Stent Placement PermaCath’s Placement Amputation Carotid Endarterectomy Arterial Surgery Aortic Abdominal Aneurysm Repair Other Yes No [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] Yes No [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] Past Surgeries Gall Bladder Appendix Hysterectomy C-Section Tubal Ligation Hernia Repair Hand Surgery Arm/Shoulder Leg Surgery Breast Surgery Other Other Yes No [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] Yes No [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] MEDICAL HISTORY & PROBLEMS Medical Problems Aneurysm Anemia Blood Clot (DVT) Carotid Disease Peripheral Arterial Disease Varicose Veins Venous Ulcers Congestive Heart Failure Heart Attack Irregular Heart Beat Hypertension High Cholesterol Seizures Other Medical Problems Stroke Cancer Diabetes Gastroesophageal Reflux Disease Thyroid Disease Dialysis When? Where? Kidney Failure Liver Disease COPD Emphysema Pneumonia/Lung Infection Asthma Other FAMILY HISTORY Has any blood relative ever had: Cancer? Diabetes? Bleeding Disorder? Vascular Problems? Heart Disease? Lung Problems? Other? Yes No [] [] [] [] [] [] [] [] [] [] [] [] [] [] Who SOCIAL HISTORY Do you use Tobacco? Yes [ ] No [ ] If no, have you ever? Yes [ ] What type? [ ] Cigarette [ ] Cigar [ ] Snuff [ ] Chewing If yes, how much a day. How long? When did you quit? Any history of illegal drug use? Yes [ ] No [ ] If so, what kind? Do you drink alcohol? Yes [ ] No [ ] If so, how much? No [ ] years How often?