Document library

Name:

Date of birth

1. Reason for consultation
PainCosmeticPreventionHeavinessBurningFatigue

2. a) Anyone in your family with :
Varicose veins
YesNo If yes - Who?
Phlebitis (blood clot)
YesNo If yes - Who?
Pulmonary embolism
YesNo If yes - Who?
b) Family history of clotting disorders (i.e.) Protein C, S, Factor V of (Leiden), antithrombine 3

3. Age that you first noticed you had varicose/spider veins?

4. Number of pregnancies?

Number of deliveries?

Are you pregnant?
YesNo
Are you breastfeeding?
YesNo

5. Any injuries to your leg (s)? (i.e. fracture):
If so, which part of leg injured?
When?

6. a) Ever have Phlebitis?(Blood clot in a vein):
YesNo
b) Were you given medication (ex: Blood thinner)
YesNo
c) How long on medication?

7. Occupation

StandingSeated

8. Do you have:
Respiratory problems / When ?Hay FeverEczema
Do you have allergies to:
TapesBandaidsAspirinXylocaine (freeze teeth)Iodine
Do you have allergies to any other medications, any foods, or anything else (list):

9. Surgeries? (List all with date)

10. Illnesses?
TuberculosisHeart ProblemsDiabetesMigraine / When?
High Blood PressureHepatitisAIDSCancerThyroidCancerArterial Problems

11. List all medications presently being taken

12. Any previous treatments for varicose and spider veins?
YesNo / When? with whom?
Do you faint with needles? YesNo

13. Where did you hear about our clinic?
DoctorFriendsNewspaperOther

14. Will you be leaving Canada for more than one year in the near future?
YesNo

15. Are you a Canadian citizen?
YesNo

Send

submit