Name
Birthday
Phone Number
Medical History
Current Medications
Do you have a family history of varicose veins or spider veins?
How many years have you had varicose veins or spider veins?
When did you first notice your veins?
Do you have or had:
Rows
Right
Left
Both
N/A
Unsightly Veins
Aches/pains
Itching
Heaviness/Throbbing
Bleeding from veins
Leg Ulcers
Pigmentation/Discoloration
Blood Clots
Have you had phlebitis, if so when?
Have you had previous treatment, if so when?
Ligation/ Vein stripping, if so when?
Previous sclerotherapy, if so when and where?
Have you worn compressions stockings?
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