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Name __________________________ Date of Birth ______________ Date _____________ Age _______ Gender Male Female Were you referred to us by your doctor? Yes No Doctor’s name: _______________________ If your answer was no then how did you hear about us? _________________________________ Tell Us About Your Vein Problems: Describe the problems you have with your legs and/or veins: ______________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Do you have bulging veins? Yes No Do you have spider veins? Yes No How many years have you had vein problems? __________ What is/was your occupation? _________________________________________________________ Do you have any varicose veins on your lower abdomen or groin area? Yes No Do you take the medication minocycline (Minocin)? Yes No Women: How many children have you delivered? __________ Have you had two or more miscarriages? Yes No Did your pregnancies cause any vein problems? Yes No Do you have any pelvic or vaginal varicose veins? Yes No Have you delivered a baby within the last 60 days? Yes No Is there any chance that you could currently be pregnant? Yes No Men: Do you have a varicocele (large varicose vein in scrotum)? Yes No Have you ever worn prescription compression hose for your veins? Yes No How long did you wear them? __________________________________________________ What effect did they have on your symptoms? _____________________________________ Regarding your legs, do you have? How are your leg problems affected by the following: Taking pain medication (prescription or non-prescription) Better Worse No change Have you ever had any of these problems? Some insurance companies require information on how your vein problems interfere with the quality of your life or with your ability to perform the normal activities of daily living such as walking, working, gardening, playing with your children/grandchildren, having to stop activities in order to elevate your legs, etc. Please tell us how your veins affect your life (please do not include issues of appearance). ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Have you had treatments for your veins in the past? Yes No What treatments? __________________________________________________________ When were they done? ______________________________________________________ Physician or facility performing treatment? _______________________________________ Medical History: Besides vein problems, what medical conditions/diseases/problems do you have? _____________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ What medications do you take (include all non-prescription medications and supplements)? _____ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Are you allergic to any medications? Yes No What? _________________________________ Family History: Do any family members have varicose veins? Yes No Who? _____________________________________________________________________ Have any family members had a deep vein blood clot (DVT) or a pulmonary (lung) blood clot? Yes No Who? ___________________________________________________________ Do any family members have a blood clotting problem? Yes No Who? ___________________________________________________________


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