Medical Questionnaire

MEDICAL QUESTIONNAIRE

Primary Care Physician:______Date: ______

Last Name:______First: ______DOB: ______

BP: ______/______HR: _____ Height ______Weight______Pharmacy: ______

Current Smoker: Yes No Packs per day ______per week: ______Are you a Former smoker: Yes No

Alcohol: Yes No Amount per day: ____ per week: ____ per month: ____

(circle all that apply and indicate reaction) (circle all that apply)

ALLERGIES: REACTION: Current and Past Medical Conditions:

No Allergies ______Diabetes High Blood Pressure

Sulfa ______Heart Disease Prolonged Bleeding

Codeine ______Cancer Pulmonary Embolus

Iodine ______Stroke Thyroid Condition

Latex ______Phlebitis Vein Ulceration

Penicillin ______Anemia Other: ______

Anesthetics ______

Other (List) ______Current Exercise Habits:______

Family History of Varicose/Spider Veins: Yes No # of Pregnancies: _____ # of Children: ______

Have you worn compression stockings: Yes No How Long: weeks ______months ______

Previous Vein Treatment: ______

Previous Operations: ______

Leg Symptoms you are having now (circle all that apply):

Heaviness Aching Fatigue Night Cramps Focal Pain Burning Swelling

Tenderness Leg Cramps Throbbing Leg Ulcers Edema Itching Other:

List all medications you are taking – prescription and over-the-counter:

Medication / Dosage / Reason

______ It is our policy to take photos of your varicose veins. These photos will be used for

(Initial) submitting to insurance carriers or to be maintained in your medical record only.