Patient History Template printable pdf download

Name: _________________________________________

Patient History

Date: ____________Date of Birth: __________ Age: ____

Symptoms:

Check if you’ve had any of the following:

(Please check if yes)

 



Aching / pain in legs

Heart disease

 



Heaviness

Peripheral arterial disease

 



Tiredness / fatigue

HIV

 



Itching / burning / warmth

Hepatitis

 



Leg cramping

High blood pressure

 



Leg restlessness

Diabetes

 



Throbbing

Cancer

 



Swelling

Leg trauma / surgery



Asthma/COPD



Do your symptoms interfere with your sleep?



Major surgery / hospitalizations:



Are your symptoms worse later in the day?

_______________________________________________



Are your symptoms worse with or after activity?

_______________________________________________



Do your symptoms keep you from doing anything?

________________________________________________

Yes

Do you have an Advanced Directive?

Do you have any Peripheral Arterial Disease (PAD) Symptoms? Check all that apply:

 Was diagnosed with PAD in past

 Have/had cramping leg pain that worsens with walking, forcing me to stop walking

 Feet/toes become pale and painful with exercise or when elevating them

 Have/had ulcers on feet or toes

Conservative Measures Used Currently or Previously: (please check those measures that you have tried)

 Pain medications

 Weight loss

 Leg elevation

 Job change

 Exercise

 Compression stockings or leg wraps? Strength of stockings: __________ mmHg

Please list your weight: __________ lbs and height: ____ft ____in

Restless Legs Syndrome:

(Please check box if yes)



Do you find the need to move your leg(s) to relieve an uncomfortable feeling?



Do(es) your leg(s) feel better when moving it (them) or walking?



Are your leg symptoms worse when sitting or resting, without elevating your leg(s)?



Are your leg symptoms worse later in the day or night?

Please check below if you have, or have had, any of the following:

 A prior evaluation for your veins: ______________

 A family history of vein disease

(yr)

 Previous vein surgery or laser treatments: _________

 A family history of leg ulceration

(yr)____R____L

 Previous vein injections: _________

 A family history of blood clots

(yr)____R____L

 Bleeding from a vein: _________

 A family history of a clotting

(yr)____R____L

 A leg ulceration: _________

disorder

(yr)____R____L

 Superficial thrombophlebitis or an inflammation of a vein: _________

(yr)____R____L______________________ ( Location)

 Any type of blood clot: _________

(yr)____R____L______________________________________________ (Location)

 Any type of clotting disorder: ______________________________________________

(Diagnosis)

 Migraines with aura

 Diagnosed with a PFO (patent foramen ovale)

Women Only:

(Please check box if yes)

Are you pregnant or considering a pregnancy sometime in the future? 

Are you breast-feeding? 

Are your legs more painful associated with menstruation? 

Have you been diagnosed with Pelvic Congestion Syndrome and/or had bulging veins during pregnancy? 

Number of Pregnancies:_____ Deliveries:_____ Miscarriages:_____ Children’s ages:______________________

Provider reviewed with patient:__________________________________________________ Date: _____________

VCA Patient History Form

Page 1 of 2

October 2, 2017

Patient History Template

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