Natural Medicine & Rehabilitation



Name: Date of Birth: M F

Please Circle yes (Y) or no (N). If Y, please indicate right (R) or left (L)

Vascular History

1. Do you have or have you ever been diagnosed with:

Varicose Veins Y N R L

Phlebitis (Vein Redness/ Tenderness) Y N R L

Blood Clot(s) Y N R L

Deep Vein Thrombosis (DVT) Y N R L

Saphenous Vein Reflux Y N R L

2. Do you experience any of the following in your leg(s):

Aching/ Pain Y N R L

Heaviness Y N R L

Tiredness/ Fatigue Y N R L

Itching/ Burning Y N R L

Swelling Y N R L

Cramps Y N R L

Restless Leg(s) Y N R L

Throbbing Y N R L

Skin/ Ulcer Problems Y N R L

Others:

3. Which of the following do you do to improve your leg vein symptoms?

Elevation Y N R L

Support Hose Y N R L

Medication(s): N

Family History

1. Have any of your family members had:

Varicose Veins Y, who? N

Vein Stripping Y, who? N

Blood Coagulation Disorder(s) Y, who? N

Blood Clot(s) Y, who? N

Stroke Y, who? N

Heart Attack(s) Y, who? N

Pulmonary Emboli Y, who? N

Vein Treatment History

1. Have you ever been treated for varicose veins with:

Sclerotherapy Y N R L

Laser Therapy (Spider Veins) Y N R L

Phlebotomy Y N R L

Vein Stripping Surgery Y N R L

RF Ablation (VNUS Closure) Y N R L

Daily Activities

1. Do you:

Sit For Prolonged Periods Y N

Stand For Prolonged Periods Y N

Exercise Regularly Y N

Smoke Y N

How many pregnancies, if any, have you had?

CLINICAL USE ONLY

RT LT

[pic]

RT Leg:

No signs of venous disease

Varicose Veins

Spider Veins

Pigmentation

Healed Ulcers

Active Ulcers

LT Leg:

No signs of venous disease

Varicose Veins

Spider Veins

Pigmentation

Healed Ulcers

Active Ulcers

Clinical Assessment:

Treatment Plan:

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