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Venous Medical History
Please fill out each section to the best of your ability.
*	Name:
	Date:
*	Date of Birth:
*	Phone Number:
	Primary Physician:
	Referring Physician:
	Do you have varicose veins?	YesNo
	Do you have Spider Veins?	YesNo
	If yes to either, how long have you had them?
	Have you had any of the following venous procedures? Sclerotherapy, EVLT, Spider Vein Laser, Stripping, Venous Closure Phlebectomy	YesNo
	If so when/where?
	Check any symptoms you have had:	None Aching Pain Heaviness Tiredness Fatigue Restless Legs Itching Burning Swollen Ankles Leg Cramps Throbbing Skin Color Changes Swollen Legs Leg Ulcers
	How do these symptoms impact your daily living?
	Have you worn compression stockings?	YesNo
	If yes, for how long?
	When did you last wear compression stockings?
	Do they relieve your symptoms?
	Do your daily activities prolong standing?	YesNo
	If yes, how many hours per day do you stand?
	Is there anything that relieves your symptoms?
	List any medications you are taking:
	List any medications you are allergic to:
	Check any of the following you have a history of:	Heart Disease Kidney Disease Bleeding Problems Lung Disease Arthritis Leg Injuries Lupus Cancer High Blood Pressure Low Blood Pressure Blood Clots Diabetes
	List any surgeries you have had:
	If female, are you pregnant now?
	How many pregnancies have you had?
	How did you hear about us?	NewspaperRadioBrocureFriendOther
	Reason for visit:	U/S Screen AppointmentEVLT AppointmentFollow-Up