Venous Health History Form

Name

Date

Age

Sex

Male Female

Doctor Name

Directions

Please answer the following questions. Provide your best estimate for dates of occurrence.

Past Medical History

Have you ever had vein stripping surgery?

Yes No

If yes, when and which leg?

Have you ever had vein injections?

Yes No

If yes, when, which leg, and where on the leg?

Have you ever had a blood clot?

Yes No

If yes, which leg and when?

Have you ever had phlebitis?

Yes No

If yes, which leg and when?

Family History

Does anyone in your family have (or used to have) varicose veins, spider veins, leg ulcers, or swollen legs?

Yes No

If yes, which relative(s)?

Do you experience any of the following?

Heaviness?

Yes No

Aching/pain in your legs?

Yes No

Tiredness/fatigue?

Yes No

Itching/burning?

Yes No

Leg cramps?

Yes No

Swollen ankles?

Yes No

Restless legs?

Yes No

Throbbing?

Yes No

Other?

Yes No

If other, please describe:

Do you experience these problems in just one, or both legs?

One Both

Have your veins gotten worse in recent months?

Yes No

Do you elecate your legs to relieve discomfort?

Yes No

Do you take any medication for pain? (eg, advil, etc.)

Yes No

If yes, what medication and how often?

Do you wear support hose prescribed by a doctor?

Yes No

If yes, what type and how long have you worn them?

Do you wear light support hose? (eg, sheer energy)

Yes No

Do they provide relief?

Yes No

Do you have any problem walking?

Yes No

If yes, how does it affect you?

Do you stand much at work?

Yes No

Do you stand much at home?

Yes No

Have you ever had any test(s) done on your veins?

Yes No

If yes, when, what type test and where on the leg?

Were you diagnosed with saphenous vein reflux?

Yes No

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