Please complete the form below, prior to your appointment. Don't forget to click "Submit" at the end of the form. No need to print anything once you click submit.

Click on the following links for paper versions to print and fill-out: Medical Information Form or Registration Form

Haga clic en los siguientes enlaces para las versiones en papel para imprimir y rellenar: Forma De Información Médica o Forma De Registracion

Venous History

Please answer the following questions to the best of your ability

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Family History (Check all that apply)

Not ApplicableMotherFatherGrandmotherGrandfatherSibling
Vein disease / varicose veins
Premature coronary disease (under age 55)
Blood clots / phlebitis
Arterial disease / blockages in neck or leg arteries

Social History

Medical & Surgical History

Venous History

no troubleslight troublemoderate troubleconsiderable troublecould not do it
Remaining standing for a long time
Doing certain jobs at home (e.g. standing and moving around in the kitchen, cleaning the floor, or other house projects...)
Sitting for long periods of time.
Going out for the evening, to a wedding, a party, a cocktail party...
not at alla littlemoderatelya lotcompletely
I felt nervous / tense
I got tired quickly
I felt I was a burden
I felt embarrassed about my legs
I got irritated easily
I always had to be cautious
I felt as if I was handicapped
I found it hard to get going in the morning
I did not feel like going out
not bothered or limiteda little bothered / limitedModerately bothered / limitedvery bothered / limitedextremely bothered / limited
seldomfairly oftenvery oftenevery night
Not at allBetween 1 and 5 daysBetween 6 and 10 daysFor more than 10 days
Right leg pain
Left leg pain
None at allBetween 1 and 5 daysBetween 6 and 10 daysFor more than 10 days
Right leg pain pills
Left leg pain pills
None at allBetween 1 and 5 daysBetween 6 and 10 daysFor more than 10 days
Right leg swelling
Left leg swelling