Vein Health History

Please correct the errors described below.

Please Check All That Apply:

Leg Ulcers: (Check All That Apply)

Vein History: (Check all that apply)

**Compression Stocking Use:

**At least 3 months recent continuous stocking use is required for ablation preauthorization for most insurances** I have achieved relief of symptoms with:

Medical History

Female Medical History:

Vaccination History:

Surgical History:

Family History:

Is there a history in your family of spider or varicose veins?

Is there a history in your family of deep venous thrombosis, stroke or clotting disorders? (Note which)

Add Family Member

Do any major medical problems run in your family? Include consideration of the following: diabetes, heart disease, respiratory problems, high blood pressure, kidney disease, cancer, bleeding problems, breast problems, thyroid problems, thyroid problems, or gastrointestinal problems. Please list your primary relatives and the status of their health:

Add Family Member

Social History:

Medication Allergies

Medications

Add Medication

Review of Systems (Please check all that apply)

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