Name: Date:

What health issue brings you to the office today?

What are your major concerns or fears about this issue?

How long has the problem been present?

Does this interfere with the quality of your life or do you have to adjust your activities because of it? Give examples.

Does the problem interfere with your ability to be independent? Give examples.

Have you had any previous treatments? Please list.

Do your legs swell?

Does the swelling improve after a night of rest?

Do you have varicose veins? Where?

Have you ever had a clot in the veins of your leg?

Do other family members have varicose veins?

Does it interfere with your ability at work? Give examples.

Have you had leg ulcers?

Do you have a brownish discoloration of your ankles?

Have you had any previous vein ultrasounds?

Vascular Risk factors

Do you smoke cigarettes? Did you use to? When did you quit?

Do you have high blood pressure?

Do you have high cholesterol or triglycerides?

Do you have diabetes?

List your medications and allergies? (Bring your medication bottles in a baggie with you to every office visit)

List your previous operations.

List the names of all your physicians.

neuro

Have you ever had a stroke, mini strokes, seizures? Explain.

Pulm

Do you have any problems with your lungs such as emphysema, asthma, wheezing?

Have you had to use inhalers? Explain.

Who is your cardiologist?

Have you had a recent stress test? Where?

Have you ever had a heart attack? Elaborate.

Do you know your ejection fraction? What is it?

Have you ever required coronary stents? List.

Have you had a heart bypass? If yes, what year? And where?

How is your heart now?

Any major trouble with your stomach, intestines, liver, colon? If yes, explain.

Any trouble with your kidneys?

Do you know your creatinine level? If yes, what is it?

Any history of back problems?

Do you have bad arthritis?

Do your legs bother you when you go walking?

Do you need assistance to walk?

Can you walk up a couple flights of stairs without difficulty?