VEIN SCREENING FORM



VEIN SCREENING FORMPlease complete left side of form only.Name:DOB:Sex: FORMCHECKBOX M FORMCHECKBOX FI. Vascular History V. Vein Screening (to be completed by screening provider)Do you have or have you ever been diagnosed with:Varicose vein problems FORMCHECKBOX Y FORMCHECKBOX N Leg: FORMCHECKBOX R FORMCHECKBOX LPhlebitis (vein redness/tenderness) FORMCHECKBOX Y FORMCHECKBOX N Leg: FORMCHECKBOX R FORMCHECKBOX LBlood clots FORMCHECKBOX Y FORMCHECKBOX N Leg: FORMCHECKBOX R FORMCHECKBOX LDeep vein thrombosis (DVT) FORMCHECKBOX Y FORMCHECKBOX N Leg: FORMCHECKBOX R FORMCHECKBOX LSaphenous vein reflux FORMCHECKBOX Y FORMCHECKBOX N Leg: FORMCHECKBOX R FORMCHECKBOX LDo you experience any of the following in your leg(s):Aching/pain FORMCHECKBOX Y FORMCHECKBOX N Leg: FORMCHECKBOX R FORMCHECKBOX LHeaviness FORMCHECKBOX Y FORMCHECKBOX N Leg: FORMCHECKBOX R FORMCHECKBOX LTiredness/fatigue FORMCHECKBOX Y FORMCHECKBOX N Leg: FORMCHECKBOX R FORMCHECKBOX LItching/burning FORMCHECKBOX Y FORMCHECKBOX N Leg: FORMCHECKBOX R FORMCHECKBOX LSwelling FORMCHECKBOX Y FORMCHECKBOX N Leg: FORMCHECKBOX R FORMCHECKBOX LCramps FORMCHECKBOX Y FORMCHECKBOX N Leg: FORMCHECKBOX R FORMCHECKBOX LRestless legs FORMCHECKBOX Y FORMCHECKBOX N Leg: FORMCHECKBOX R FORMCHECKBOX L Physical Exam:Throbbing FORMCHECKBOX Y FORMCHECKBOX N Leg: FORMCHECKBOX R FORMCHECKBOX LSkin or ulcer problems FORMCHECKBOX Y FORMCHECKBOX N Leg: FORMCHECKBOX R FORMCHECKBOX L CEAP Clinical Signs:Other: FORMCHECKBOX Y FORMCHECKBOX N Leg: FORMCHECKBOX R FORMCHECKBOX LWhich of the following do you currently do to improve your leg vein symptoms: RIGHT LEG (check all that apply)Medication for pain FORMCHECKBOX Y FORMCHECKBOX N What? FORMCHECKBOX No signs of venous disease FORMCHECKBOX Spider veins Elevation of legs FORMCHECKBOX Y FORMCHECKBOX N What? FORMCHECKBOX Visible varicose veins FORMCHECKBOX EdemaWear support hose FORMCHECKBOX Y FORMCHECKBOX N What? FORMCHECKBOX Pigmentation FORMCHECKBOX Healed ulcers FORMCHECKBOX Active ulcersII. Family HistoryHave any of your family members had: LEFT LEG (check all that apply)Varicose veins FORMCHECKBOX Y FORMCHECKBOX N Who? FORMCHECKBOX No signs of venous disease FORMCHECKBOX Spider veins Vein stripping FORMCHECKBOX Y FORMCHECKBOX N Who? FORMCHECKBOX Visible varicose veins FORMCHECKBOX EdemaBlood coagulation disorder FORMCHECKBOX Y FORMCHECKBOX N Who? FORMCHECKBOX Pigmentation FORMCHECKBOX Healed ulcers FORMCHECKBOX Active ulcersBlood clots FORMCHECKBOX Y FORMCHECKBOX N Who?Stroke, heart attacks or pulmonary emboli FORMCHECKBOX Y FORMCHECKBOX N Who? Clinical Assessment: FORMCHECKBOX Chronic venous insufficiency FORMCHECKBOX R FORMCHECKBOX L III. Vein Treatment History FORMCHECKBOX Other: FORMCHECKBOX R FORMCHECKBOX L Have you ever been treated for varicose veins with:Sclerotherapy FORMCHECKBOX Y FORMCHECKBOX N Leg: FORMCHECKBOX R FORMCHECKBOX L Treatment Plan:Laser therapy (spider veins) FORMCHECKBOX Y FORMCHECKBOX N Leg: FORMCHECKBOX R FORMCHECKBOX L FORMCHECKBOX Duplex ultrasound FORMCHECKBOX R FORMCHECKBOX L Phlebectomy FORMCHECKBOX Y FORMCHECKBOX N Leg: FORMCHECKBOX R FORMCHECKBOX L FORMCHECKBOX Sclerotherapy FORMCHECKBOX R FORMCHECKBOX L Vein stripping surgery FORMCHECKBOX Y FORMCHECKBOX N Leg: FORMCHECKBOX R FORMCHECKBOX L FORMCHECKBOX Medical compression stockings FORMCHECKBOX R FORMCHECKBOX L RF ablation (VNUS Closure?) FORMCHECKBOX Y FORMCHECKBOX N Leg: FORMCHECKBOX R FORMCHECKBOX L FORMCHECKBOX Other: FORMCHECKBOX R FORMCHECKBOX L IV. Personal Activities ListDoes your work require:Prolonged standing periods FORMCHECKBOX Y FORMCHECKBOX N Prolonged sitting periods FORMCHECKBOX Y FORMCHECKBOX N Do you exercise regularly? FORMCHECKBOX Y FORMCHECKBOX N Do you smoke? FORMCHECKBOX Y FORMCHECKBOX N Pregnancies FORMCHECKBOX Y FORMCHECKBOX N How many? Provider Signature _______________________ ................
................

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

Google Online Preview   Download