History and Physical
Houston Vein Specialists
David D. Shin, MD, RVT, RPVI, FACS
6550 Fannin Street, Suite 2407
Houston, TX 77030
713-790-0000
Please fill in the following information:
Date:___________________
Last Name:_____________________ First Name:____________________ Middle Initial:_____
Sex: Male Female Age:_____ Birthdate:________________
Home Address:_______________________________________________
City:____________________ State:_______________ Zip:______________
Cell Phone:_______________________________
Email Address: ___________________________
Marital Status: Single Married Divorced Widowed
Who referred you here? (Doctor/Patient/Internet):__________________________
Insurance Information: Please Give Receptionist Cards
Primary Insurance:__________________________ Policy Holder:________________________
Secondary Insurance:________________________ Policy Holder:________________________
Policy Holder Information (if not patient):
Name:_________________________________ Birthdate:___________________
Emergency Contact
Name:__________________ Relationship:______________ Phone Number:_______________
Pharmacy Information
Name of Pharmacy:___________________ Pharmacy Phone Number:____________________
Why are you here today? (check all that apply):
Spider VeinsVaricose VeinsLeg PainLeg SwellingSkin DiscolorationLeg Ulcer
Other:________________________________________________________________________
Past Medical History (Please check all that apply):
Arthritis Asthma Bleeding Disorder Blood Clots Diabetes
Heart Arrhythmias Heart Disease High Blood Pressure HIV
Kidney Disease Migraines Mitral Valve Prolapse Seizure Disorder
Peptic Ulcer Disease Stroke Hepatitis/Type_______ Cancer/Type:____________
______________________________________________________________________________
List Past Surgeries and Dates:
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Medications and Dosages:
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Allergies and Type of Reaction:
______________________________________________________________________________
Social History:
Do you smoke? Yes No
What is your occupation: _________________________________
Family History (Mark if any family member has the following problems):
Varicose Veins Blood Clots (location) ________________
Please check all symptoms that apply:
General: Weight Gain Weight Loss Fever Chills
Skin: Color Change Itching Rash
Cardiac: Chest Pain Shortness of breath
Vascular: Leg Pain Leg Ulcers Varicose Veins
Respiratory: Allergies
Gastrointestinal: Heartburn Stomach Ulcers
Women: # of Pregnancies ______ # children__________
Last Menstrual Period _______________ Menopause Tubal Ligation
Musculoskeletal: Back Pain Painful Joints Joint Swelling
Hematologic: Bleed or Bruise Easily
Name: ___________________________ Date: _____________________
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