Chesapeake Vein Center & Medspa | Chesapeake, Virginia
Venous Health HistoryPatient Name: ________________________________ Date of Birth: _____________HistoryHistoryYesNoSide AffectedDetailsVein stripping surgeryR / L / BothVein injectionsR / L / BothAny other vein procedure?R / L / BothBlood clots R / L / BothPhlebitis (tender vein)R / L / BothFamily history of Veins swelling/clotting disorder?History of miscarriagesHeart problemsKidney problemsLung problemsLymphedemaWeight change over past decadeInjury or surgeries to legR / L / BothPrevious Leg Ultrasounds/CT/MRI?Patient signature: _____________________________________ Date: _______________________Other Venous SymptomsLeg SymptomsYesNoSide Affected DetailsHeavinessR / L / BothTiredness/fatigueR / L / BothCramping/throbbing R / L / BothItching/burningR / L / BothNumbness/tinglingR / L / BothRestless Leg FeelingR / L / Both“Neuropathy” historyR / L / BothSymptoms worsening?R / L / BothDo you take meds for your legs?Do you elevate your legs at night?Do you exercise?Your profession? How long do you stand in a day? Do symptoms impact Quality of Life? Do symptoms impact day to day activities?How did you hear about us?Any other relevant infoPatient signature: _____________________________________ Date: _______________________VCSSItemAbsent (0)Mild (1)Moderate (2)Severe (3)Side Affected Pain or AcheNoneOccasionalDailyDaily limitingR / L / BothVisible Varicose veinsNoneFewCalf or thighCalf and thighR / L / BothLeg Swelling NoneFoot and ankleUp to Knee Above KneeR / L / BothSkin darkeningNoneAt ankleUp to lower calfAbove lower calfR / L / BothSkin reddeningNoneAt ankleUp to lower calfAbove lower calfR / L / BothSkin thickeningNoneAt ankleUp to lower calfAbove lower calfR / L / BothNumber of Ulcers None12>3R / L / BothUlcer durationNone< 3 months3-12 months> 1 yearR / L / BothUlcer sizeNone< 2 cm (3/4 in)cm (3/4 in – 2 in)> 6 cm (> 2in)R / L / BothCompression therapyNoneOccasionalMost daysEvery dayR / L / BothPatient signature: _____________________________________ Date: _______________________FAQWhat is superficial venous reflux?Superficial venous reflux is a condition that develops when the valves that usually keep blood flowing out of your legs become damaged or diseased. This causes blood to pool in your legs. Common symptoms include pain, swelling, leg heaviness and fatigue, as well as varicose veins in your legs.What are the risk factors for superficial venous reflux?Older ageFamily historyPrevious or present deep vein blood clotsHistory of phlebitisObesityStanding occupationPregnancyFemale genderWhat are the common symptoms of superficial venous reflux? Pain or aching or throbbing or cramping in legsLeg heaviness and fatigue as the day progressesSwelling worse by end of dayVaricose veinsSpider veinsNumbness, weakness (when other neurology workup has been negative)Restless legsRedness or brownish or blackish discoloration of ankles, lower legsDoes this condition progress?Yes, it does progress throughout your life. As the disease has a genetic component, there is no ‘cure’. However, the condition can be controlled initially by lifestyle modifications in general, and later by office-based interventions which target and treat the veins with the diseased valves. Interventions also slow down the speed of progression of reflux disease. What are the treatments available and why should I consider them?LifestyleSurgical (rare)Targeted procedures (office)Exercise or walkVein Stripping (hospital, rare)Vein ablations Putting legs up at night Microphlebectomy (office)Spider Vein injectionsWeight lossLarge Vein sclerotherapyReduce saltCompression stockings ................
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