CONSULT: VERICOSE VEINS

2090-A W Arlington Blvd, Greenville, NC 27834

Mon¨CFri 7:45am¨C4pm

252.754.5253 |

Patient Name_______________________________________ DOB ____ /____ /____ Date ____ /____ /____ MRN __________

CONSULT: VERICOSE VEINS

What brought you to our clinic: ______________________________________________________________________________

________________________________________________________________________________________________________

Which leg troubles you?

Right

Left

Both (if both, which one is worse)_____________________

How long have you had leg issues: ____________________________________________________________________________

Leg Symptoms and concerns: Please circle

Leg pain

Bulging veins

Unattractive veins

Spider veins

Aching

Throbbing

Tiredness

Heaviness

Tenderness

Itching

Burning

Wound

Ulcer

Skin Changes

Swelling

Bleeding

Redness

Warmth

Night Cramps

Other: ___________________________________?????___________________________________________

What makes your symptoms feel worse:

Prolonged standing

Prolonged sitting

Walking

How have you been treating your legs: Please circle

Compression Hose

Surgery/stripping

Medicine

Rest

Elevation

Other: ___________________________________?????___________________________________________

Have you been treated by a physician for your leg symptoms in the past, including surgeries, stripping, or injections: YES NO

If yes please describe: ______________________________________________________________________________________

Does anyone in your family have similar leg issues: _______________________________________________________________

Have you ever been diagnosed with: Please circle

DVT

Pulmonary embolism

Hypercoagulability

Superficial thrombophlebitis

What activities are impacted by your leg symptoms: Please circle

Exercise

Housework

Yardwork

Gardening

Cooking

Driving

Shopping

Traveling

Shopping

Other: ___________________________________?????___________________________________________

What medical conditions do you have: Please circle

High blood pressure

Heart disease

DVT/Leg clots

Diabetes

Bleeding disorder

Stroke

Kidney disease

Cancer

Other: ___________________________________?????___________________________________________

What other surgeries have you had:___________________________________________________________________________

________________________________________________________________________________________________________

What medicines do you take: ________________________________________________________________________________

________________________________________________________________________________________________________

REV. 3.25.16

List any medicines or other things you are allergic to: ____________________________________________________________

________________________________________________________________________________________________________

Where do you work? If you are retired describe your previous job: __________________________________________________

________________________________________________________________________________________________________

Do you smoke:

YES

NO

Do you drink alcohol, beer, or wine?

YES

NO

If yes how many packs/day:____________________________

Are you experiencing any of the following symptoms today? Please circle all that apply

fever /chills

weight loss

decreased appetite

fatigue

rash

itching

easy bruising

jaundice

hearing loss

vision changes

decreased vision

sore throat

shortness of breath

cough

wheezing

bloody cough

chest pain

palpitations

weakness on exertion

leg swelling

nausea/vomiting

constipation

bloody stool

diarrhea

painful urination

bloody urine

decreased urination

incontinence

dizziness

weakness

headache

paralysis

speech changes

confusion

loss of coordination

tremor

joint pain

joint swelling

numbness or tingling

stiffness

anxiety

depression

thoughts of suicide

memory loss

poor sleep

Hwy 43

/5th Str

eet

He

Be

Brody School of Medicine

McDonald¡¯s

ECU Heart Institute

Vidant Medical Center

Fire Station

Hemby Lane

Arlington Boulevard

Spri

Greenville MRI

&

Breast Imaging Center

Stantonsburg Rd.

Turn onto

Hemby Ln

& then into

parking lot

Eastern

Interventional

Radiology

Mem

Bank

Doctors Park

lvd.

First Citizens Bank

oria

l Dr

ive

Do

cto

Par rs

k

rvi

Driv

e

ical

ve

Moye B

Dr.

Dri

W.H. Smith Blvd.

ng F

ores

t

Bet

Gray

Rd.

Firehouse Subs, Tropical Smoothie

Lemongrass, K & W Cafeteria

man

burg

Med

Bow

nton

s

Arlington Crossing

/Sta

Johns Hop

kins Dr.

264

hes

da D

rive

Hwy

Arlin

g

Stanton Square

ey

ve

ce

D

ton

B

oule

asl

Dri

Se

vard

art

riv

e

MacGregor Do

wns

Breast Imaging Center

2101 W. Arlington Blvd.

Suite 100

Greenville MRI

2101 W. Arlington Blvd.

Suite 110

Interventional Radiology

2090-A W. Arlington Blvd.

Doctors Park

#9 & #10 Doctors Park

(252)752-5000

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download