Download Patient History Form - Total Vein Concepts

Greenbrier Healthplex
713 Volvo Parkway, Suite 105  Chesapeake, Virginia 23320
Phone (757) 893-1413
Patient History Form
Reason for visit today?___________________________________________________________________
1) Have you had any prior treatment for varicose/spider veins?
Date(s) of treatment:
Type of agent(s) used, if known
2) Do you have any history of skin ulcerations, clots in veins, or deep vein thrombosis?
3) Do you have a family history of varicose veins?
If so, relationship(s) to you.
4) Are you currently, or have you been on any hormone therapy or birth control pills?
If so, please list
5) Have you had any pregnancies?
Are you currently pregnant or nursing?
If so, how many?
Age of children?
6) Have you ever worn compression stockings?
If yes, when did you first use the stockings?
Did they help?
7) Are you presently employed?
If so, type of job.
8) Do you sit or stand for long periods of time?
How many hours per day?
9) Do you take any pain medications for your varicose/spider veins/leg pain (Aspirin, Tylenol, Advil,
Aleve, Motrin)?
10) Do you elevate your legs to relieve your symptoms?
If so, does it work?
11) Are you currently taking:
Coumadin, Aspirin, Plavix, Lovenox, or any blood thinners?
12) Are you currently using a tanning bed?
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Greenbrier Healthplex
713 Volvo Parkway, Suite 105  Chesapeake, Virginia 23320
Phone (757) 893-1413
VENOUS HISTORY CHECKLIST
(Please check all those that apply)
Left Leg
Right Leg
Throbbing legs
Swelling
Pain
Tiredness
Burning of legs
Skin color changes
Spider veins
Bulging veins
Restless legs
Leg cramps
Itching of legs
Leg heaviness
Do you have a history of…..?
1) High blood pressure
2) Heart disease or chest pain
3) Diabetes
4) Lung disease or shortness of breath
5) Liver disease
6) Cancer
7) Skin disorders for which you sought medical treatment
8) Arthritis
9) Stroke
10) Bleeding veins
11) Slow or non-healing wounds to legs or feet
12) Bleeding/Clotting disorders
13) Leg pain with activity
14) Blood clots in veins or lungs
15) Do you smoke
16) Consume alcohol
17) Infection/inflammation of veins
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
Please explain any “Yes” answers
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Additional Medical
History:_______________________________________________________________________________
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Greenbrier Healthplex
713 Volvo Parkway, Suite 105  Chesapeake, Virginia 23320
Phone (757) 893-1413
Please List:
Drug Allergies:
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Surgeries:
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Medications (with doses):
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Approximate weight and height: ___________________
Patient signature______________________________________
Date____________________
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