New Patient Questionnaire | LASER VEIN REMOVAL WEB CENTER

	Family History

1.	Has anyone in your FAMILY had varicose veins, venous reflux, leg ulcers or swollen legs?
		(check all that apply)
	Mother	yes
	Father	yes
	Grandparents	yes
	Siblings	yes
	Aunt/Uncle	yes
	Child	yes
	Add additional information:	(optional)


5.	If you have worn compression stockings, what is the earliest date of use for your leg problems? *some insurance plans require compression stockings be worn 6 months prior to request for treatment		Month: Year:


6.	How have your daily activities been affected or limited by your leg problems?	please describe



7.	Have you been treated for your veins before?	yes	no
	If "yes", what method?
		(check all that apply)
	Cosmetic injections		Radiofrequency closure
	Stripping		Laser catheter ablation
	Ligation		Laser for spider vein
	Ambulatory phlebectomy
	Ultrasound-guided injections		Other treatments:	please describe

	Symptoms

2.	Do you experience any of the following symptoms in your legs?
		(check all that apply)
	Heaviness?	left leg	right leg	both legs
	Tiredness/fatigue?	left leg	right leg	both legs
	Itching/burning?	left leg	right leg	both legs
	Swelling?	left leg	right leg	both legs
	Cramping?	left leg	right leg	both legs
	Throbbing?	left leg	right leg	both legs
	Restless Legs?	left leg	right leg	both legs
	Ulceration?	left leg	right leg	both legs
	Phlebitis?	left leg	right leg	both legs
	Other?	please describe


3.	Please check if you have any of the following:
		(check all that apply)
	Red spider veins	yes
	Purple veins	yes
	Bulging veins	yes
	Abdominal veins	yes
	Flat bluish-green veins	yes
	Skin discoleration below your knee	yes
	Diagnosis of vein disease	yes
	Other (please describe >>)	please describe

	Vascular History

4.	Please check any methods you have used to relieve your leg discomfort:
		(check all that apply)
	No discomfort		Warm soaks
	Leg elevation		Cold packs
	Exercise		Pain medications
	Flexing/extension of your feet		Aspirin
	Walking		Tylenol
	Support/Compression Stockings		Ibuprofen
	Wraps		Other methods:	please describe