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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