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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? 1 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 ______________________________________________________________________________________ ______________________________________________________________________________________ Additional Medical History:_______________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ 2 Greenbrier Healthplex 713 Volvo Parkway, Suite 105 Chesapeake, Virginia 23320 Phone (757) 893-1413 Please List: Drug Allergies: ______________________________________________________________________________________ ______________________________________________________________________________________ Surgeries: ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Medications (with doses): ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Approximate weight and height: ___________________ Patient signature______________________________________ Date____________________ 3