Please complete the form below, prior to your appointment. Don't forget to click "Submit" at the end of the form. No need to print anything once you click submit.

Click on the following links for paper versions to print and fill-out: Medical Information Form or Registration Form

Haga clic en los siguientes enlaces para las versiones en papel para imprimir y rellenar: Forma De Información Médica o Forma De Registracion

Venous History

Please answer the following questions to the best of your ability

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Family History (Check all that apply)

Not ApplicableMotherFatherGrandmotherGrandfatherSibling
Vein disease / varicose veins
Not Applicable
Mother
Father
Grandmother
Grandfather
Sibling
Premature coronary disease (under age 55)
Not Applicable
Mother
Father
Grandmother
Grandfather
Sibling
Blood clots / phlebitis
Not Applicable
Mother
Father
Grandmother
Grandfather
Sibling
Arterial disease / blockages in neck or leg arteries
Not Applicable
Mother
Father
Grandmother
Grandfather
Sibling

Social History

Medical & Surgical History

Venous History

no troubleslight troublemoderate troubleconsiderable troublecould not do it
Remaining standing for a long time
no trouble
slight trouble
moderate trouble
considerable trouble
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 trouble
slight trouble
moderate trouble
considerable trouble
could not do it
Sitting for long periods of time.
no trouble
slight trouble
moderate trouble
considerable trouble
could not do it
Going out for the evening, to a wedding, a party, a cocktail party...
no trouble
slight trouble
moderate trouble
considerable trouble
could not do it
not at alla littlemoderatelya lotcompletely
I felt nervous / tense
not at all
a little
moderately
a lot
completely
I got tired quickly
not at all
a little
moderately
a lot
completely
I felt I was a burden
not at all
a little
moderately
a lot
completely
I felt embarrassed about my legs
not at all
a little
moderately
a lot
completely
I got irritated easily
not at all
a little
moderately
a lot
completely
I always had to be cautious
not at all
a little
moderately
a lot
completely
I felt as if I was handicapped
not at all
a little
moderately
a lot
completely
I found it hard to get going in the morning
not at all
a little
moderately
a lot
completely
I did not feel like going out
not at all
a little
moderately
a lot
completely
not bothered or limiteda little bothered / limitedModerately bothered / limitedvery bothered / limitedextremely bothered / limited
not bothered or limited
a little bothered / limited
Moderately bothered / limited
very bothered / limited
extremely bothered / limited
seldomfairly oftenvery oftenevery night
seldom
fairly often
very often
every night
Not at allBetween 1 and 5 daysBetween 6 and 10 daysFor more than 10 days
Right leg pain
Not at all
Between 1 and 5 days
Between 6 and 10 days
For more than 10 days
Left leg pain
Not at all
Between 1 and 5 days
Between 6 and 10 days
For more than 10 days
None at allBetween 1 and 5 daysBetween 6 and 10 daysFor more than 10 days
Right leg pain pills
None at all
Between 1 and 5 days
Between 6 and 10 days
For more than 10 days
Left leg pain pills
None at all
Between 1 and 5 days
Between 6 and 10 days
For more than 10 days
None at allBetween 1 and 5 daysBetween 6 and 10 daysFor more than 10 days
Right leg swelling
None at all
Between 1 and 5 days
Between 6 and 10 days
For more than 10 days
Left leg swelling
None at all
Between 1 and 5 days
Between 6 and 10 days
For more than 10 days