Patient Forms | Varicose Vein Treatment in Tempe

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Venous History

Please answer the following questions to the best of your ability

Please briefly describe your symptoms and what brings you in:

First Name

Last Name

Mobile Phone

Other Phone

Address

City

US States

Zip

Gender

Date of Birth

Primary Care Physician

Marital Status

Single
Married
Divorced
Widowed

Ethnicity

Hispanic or Latino
Not Hispanic or Latino
Refuse to Report

Current Medications

Medication Allergies

Pharmacy Name & Phone Number or Cross Streets

Family History (Check all that apply)

	Not Applicable	Mother	Father	Grandmother	Grandfather	Sibling
Vein disease / varicose veins	Not ApplicableVein disease / varicose veins Not Applicable	MotherVein disease / varicose veins Mother	FatherVein disease / varicose veins Father	GrandmotherVein disease / varicose veins Grandmother	GrandfatherVein disease / varicose veins Grandfather	SiblingVein disease / varicose veins Sibling
Premature coronary disease (under age 55)	Not ApplicablePremature coronary disease (under age 55) Not Applicable	MotherPremature coronary disease (under age 55) Mother	FatherPremature coronary disease (under age 55) Father	GrandmotherPremature coronary disease (under age 55) Grandmother	GrandfatherPremature coronary disease (under age 55) Grandfather	SiblingPremature coronary disease (under age 55) Sibling
Blood clots / phlebitis	Not ApplicableBlood clots / phlebitis Not Applicable	MotherBlood clots / phlebitis Mother	FatherBlood clots / phlebitis Father	GrandmotherBlood clots / phlebitis Grandmother	GrandfatherBlood clots / phlebitis Grandfather	SiblingBlood clots / phlebitis Sibling
Arterial disease / blockages in neck or leg arteries	Not ApplicableArterial disease / blockages in neck or leg arteries Not Applicable	MotherArterial disease / blockages in neck or leg arteries Mother	FatherArterial disease / blockages in neck or leg arteries Father	GrandmotherArterial disease / blockages in neck or leg arteries Grandmother	GrandfatherArterial disease / blockages in neck or leg arteries Grandfather	SiblingArterial disease / blockages in neck or leg arteries Sibling

Social History

Do you smoke tobacco?

Do you drink alcohol?

Medical & Surgical History

Surgical History

Venous History

2) How long have your legs bothered you?

3) Does one leg bother you more than the other?

4) How much leg pain/discomfort have you had in the past 4 weeks?

5) At what time of day are leg symptoms the worse?

6) Are leg symptoms made worse by heat?

7) Have you ever worn compression stockings?

7a) Have you done leg exercises and leg elevation?

8) Have you had lower extremity vein / vascular treatment in the past?

10) During the past 4 weeks, how much trouble have you had carrying out the actions and activities listed below because of your leg problems?

	no trouble	slight trouble	moderate trouble	considerable trouble	could not do it
Remaining standing for a long time	no troubleRemaining standing for a long time no trouble	slight troubleRemaining standing for a long time slight trouble	moderate troubleRemaining standing for a long time moderate trouble	considerable troubleRemaining standing for a long time considerable trouble	could not do itRemaining standing for a long time could not do it
Doing certain jobs at home (e.g. standing and moving around in the kitchen, cleaning the floor, or other house projects...)	no troubleDoing certain jobs at home (e.g. standing and moving around in the kitchen, cleaning the floor, or other house projects...) no trouble	slight troubleDoing certain jobs at home (e.g. standing and moving around in the kitchen, cleaning the floor, or other house projects...) slight trouble	moderate troubleDoing certain jobs at home (e.g. standing and moving around in the kitchen, cleaning the floor, or other house projects...) moderate trouble	considerable troubleDoing certain jobs at home (e.g. standing and moving around in the kitchen, cleaning the floor, or other house projects...) considerable trouble	could not do itDoing certain jobs at home (e.g. standing and moving around in the kitchen, cleaning the floor, or other house projects...) could not do it
Sitting for long periods of time.	no troubleSitting for long periods of time. no trouble	slight troubleSitting for long periods of time. slight trouble	moderate troubleSitting for long periods of time. moderate trouble	considerable troubleSitting for long periods of time. considerable trouble	could not do itSitting for long periods of time. could not do it
Going out for the evening, to a wedding, a party, a cocktail party...	no troubleGoing out for the evening, to a wedding, a party, a cocktail party... no trouble	slight troubleGoing out for the evening, to a wedding, a party, a cocktail party... slight trouble	moderate troubleGoing out for the evening, to a wedding, a party, a cocktail party... moderate trouble	considerable troubleGoing out for the evening, to a wedding, a party, a cocktail party... considerable trouble	could not do itGoing out for the evening, to a wedding, a party, a cocktail party... could not do it

11) Leg problems can also affect your spirits. How closely do the following statements correspond to how you have felt during the past 4 weeks?

	not at all	a little	moderately	a lot	completely
I felt nervous / tense	not at allI felt nervous / tense not at all	a littleI felt nervous / tense a little	moderatelyI felt nervous / tense moderately	a lotI felt nervous / tense a lot	completelyI felt nervous / tense completely
I got tired quickly	not at allI got tired quickly not at all	a littleI got tired quickly a little	moderatelyI got tired quickly moderately	a lotI got tired quickly a lot	completelyI got tired quickly completely
I felt I was a burden	not at allI felt I was a burden not at all	a littleI felt I was a burden a little	moderatelyI felt I was a burden moderately	a lotI felt I was a burden a lot	completelyI felt I was a burden completely
I felt embarrassed about my legs	not at allI felt embarrassed about my legs not at all	a littleI felt embarrassed about my legs a little	moderatelyI felt embarrassed about my legs moderately	a lotI felt embarrassed about my legs a lot	completelyI felt embarrassed about my legs completely
I got irritated easily	not at allI got irritated easily not at all	a littleI got irritated easily a little	moderatelyI got irritated easily moderately	a lotI got irritated easily a lot	completelyI got irritated easily completely
I always had to be cautious	not at allI always had to be cautious not at all	a littleI always had to be cautious a little	moderatelyI always had to be cautious moderately	a lotI always had to be cautious a lot	completelyI always had to be cautious completely
I felt as if I was handicapped	not at allI felt as if I was handicapped not at all	a littleI felt as if I was handicapped a little	moderatelyI felt as if I was handicapped moderately	a lotI felt as if I was handicapped a lot	completelyI felt as if I was handicapped completely
I found it hard to get going in the morning	not at allI found it hard to get going in the morning not at all	a littleI found it hard to get going in the morning a little	moderatelyI found it hard to get going in the morning moderately	a lotI found it hard to get going in the morning a lot	completelyI found it hard to get going in the morning completely
I did not feel like going out	not at allI did not feel like going out not at all	a littleI did not feel like going out a little	moderatelyI did not feel like going out moderately	a lotI did not feel like going out a lot	completelyI did not feel like going out completely

12) During past 4 weeks, to what extend did you feel bothered/limited in your work or your other daily activities because of your leg problems?

not bothered or limited	a little bothered / limited	Moderately bothered / limited	very bothered / limited	extremely bothered / limited
not bothered or limitednot bothered or limited	a little bothered / limiteda little bothered / limited	Moderately bothered / limitedModerately bothered / limited	very bothered / limitedvery bothered / limited	extremely bothered / limitedextremely bothered / limited

13) During the past 4 weeks, did you sleep badly because of your leg problems, and how often?

seldom	fairly often	very often	every night
seldom13) During the past 4 weeks, did you sleep badly because of your leg problems, and how often? seldom	fairly often13) During the past 4 weeks, did you sleep badly because of your leg problems, and how often? fairly often	very often13) During the past 4 weeks, did you sleep badly because of your leg problems, and how often? very often	every night13) During the past 4 weeks, did you sleep badly because of your leg problems, and how often? every night

14) In the last 2 weeks for how many days did your veins cause you pain or ache?

	Not at all	Between 1 and 5 days	Between 6 and 10 days	For more than 10 days
Right leg pain	Not at allRight leg pain Not at all	Between 1 and 5 daysRight leg pain Between 1 and 5 days	Between 6 and 10 daysRight leg pain Between 6 and 10 days	For more than 10 daysRight leg pain For more than 10 days
Left leg pain	Not at allLeft leg pain Not at all	Between 1 and 5 daysLeft leg pain Between 1 and 5 days	Between 6 and 10 daysLeft leg pain Between 6 and 10 days	For more than 10 daysLeft leg pain For more than 10 days

15) During the past 2 weeks, on how many days did you painkillers or anti-inflammatories for your leg symptoms?

	None at all	Between 1 and 5 days	Between 6 and 10 days	For more than 10 days
Right leg pain pills	None at allRight leg pain pills None at all	Between 1 and 5 daysRight leg pain pills Between 1 and 5 days	Between 6 and 10 daysRight leg pain pills Between 6 and 10 days	For more than 10 daysRight leg pain pills For more than 10 days
Left leg pain pills	None at allLeft leg pain pills None at all	Between 1 and 5 daysLeft leg pain pills Between 1 and 5 days	Between 6 and 10 daysLeft leg pain pills Between 6 and 10 days	For more than 10 daysLeft leg pain pills For more than 10 days

16) In the last 2 weeks, how much ankle swelling have you had?

	None at all	Between 1 and 5 days	Between 6 and 10 days	For more than 10 days
Right leg swelling	None at allRight leg swelling None at all	Between 1 and 5 daysRight leg swelling Between 1 and 5 days	Between 6 and 10 daysRight leg swelling Between 6 and 10 days	For more than 10 daysRight leg swelling For more than 10 days
Left leg swelling	None at allLeft leg swelling None at all	Between 1 and 5 daysLeft leg swelling Between 1 and 5 days	Between 6 and 10 daysLeft leg swelling Between 6 and 10 days	For more than 10 daysLeft leg swelling For more than 10 days

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