PATIENT INFORMATION. Name: Date of Birth: Home Phone: Cell Phone: Work Phone: Address: Home Address: City: State ZIP: Emergency Contact: Phone:

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1 PATIENT INFORMATION Name: Date of Birth: Home Phone: Cell Phone: Work Phone: Address: Home Address: City: State ZIP: Social Security #: Marital Status: Single Married Divorced Widowed Emergency Contact: Phone: Primary Care Physician: Phone: Referring Physician: Phone: How did you hear about us: HIPPA Choices: Did you receive a copy of the HIPAA notice? YES NO Allow Voice Msg? YES NO Allow SMS (text message)? YES NO Allow postal mail? YES NO Occupation: Employer: Language: Race/Ethnicity: Primary Health Insurance Name: ID#: Group #: Subscriber: Self Spouse Other Subscriber s Name: DOB: Secondary Health Insurance Name: ID#: Group #: Subscriber: Self Spouse Other Subscriber s Name: DOB:

2 Patient Name: Height: Weight: Gender: Male Female Reason for Visit: Chief Complaint: Aching Awakened at night Bleeding from veins Burning Cramping Diff. healing wounds Fatigue Heaviness Itching Pain Restless legs Swelling Ulcers Varicose veins Spider veins Skin discoloration Other: Which Leg: Right Left Both How long: Ulcer on Leg: No Yes: which leg? for how long? Timing of Symptoms: Intermittently Mostly at night Only during daytime All day While laying down Bedtime Other: How do these symptoms affect your Activities of Daily Living Work: Daily Chores: Care for Family: Travel: Walking/Exercising: Other: Symptoms made worse by: Walking Exercise Prolonged Standing Prolonged Sitting Leg Elevation Heat Premenstrual Pregnancy Travel Other: Symptoms made better by: Resting: how often? Leg Elevation Standing Sitting Walking Exercise Heat Other: Conservative Therapy: (please check any of the conservative therapy measures you have tried) Compression Stockings Elevation Weight Reduction Exercise Avoiding Prolonged Sitting/Standing Tylenol/Motrin Other: How long have you been using conservative measures?

3 Vein History: Past Vein Procedures: Past Vein History: DVT PAD Leg Ulcers Other: Past Medical History: CAD High Cholesterol High Blood Pressure Diabetes Peripheral Vascular Disease Varicose Veins Other: Past Surgeries: Family History: Venous Disease Clotting Disorder Stroke Diabetes Hypertension Cancer Other: Social History: Alcohol: Never Rare Occasional Daily Smoking: Never Current Smoker Quit >1 year Quit 1-10 years Quit 10+ years Female History: # pregnancies planning for pregnancy Allergies: Current Medications:

4 Review of Systems: (please check all that apply) Constitutional: Fatigue Fever Recent weight loss Recent weight gain Cardiovascular: Chest pain Palpitations Shortness of Breath with walking while laying flat Swelling legs/ankles Varicose veins Respiratory: Chronic/Freq cough Cough/spit up blood Wheezing Asthma Gastrointestinal: Abdominal Pain Black tarry stools Changes in bowel habits Difficulty/Pain swallowing Heartburn Hemorrhoids Indigestion Jaundice Pain on defecation Rectal bleeding Vomiting of blood Genitourinary: Blood in urine Difficulty urinating Irregular/abnormal periods Pain or burning with urination Pain with intercourse Pain with menstruation Pelvic pain Vulvar veins Musculoskeletal: Ankle pain Back pain Foot pain Hip pain Knee pain Leg cramps Integumentary: Easy skin bruising Eczema Hair loss Heavy sweating Itching Rashes Skin lesions Ulcers Endocrine: Cold intolerance Excessive thirst Excessive urination Heat intolerance Incontinence Hematologic/Lymphatic: Bleeding tendencies Enlarged lymph nodes

5 Kelly O Donnell, M.D. 166 Defense Highway, Suite 101 Annapolis, MD A Dutchmans Lane, Suite 1 Easton, MD (410) FAX (410) ASSIGNMENT OF BENEFITS FORM I,, understand that services rendered to me by O Donnell Vein and Laser/Kelly O Donnell, M.D. are my financial responsibility and that the provider will bill my insurance company. I authorize my insurance company to pay my benefits directly to O Donnell Vein and Laser/Kelly O Donnell, M.D. and I understand that I will be fully responsible for any amount allowed and not paid by my insurance company. I am also responsible for any Deductible, Copay and/or Co-insurance. I authorize the provider to release any information necessary to adjudicate my claims. I also understand that should my insurance company send payment to me, I will forward the payment to the office in a timely manner. I certify that the information I have provided with regard to my insurance coverage is current and correct. I agree to continually provide current and accurate health insurance information should any changes occur. I agree to notify the office of any updated insurance information prior to any services being rendered. I authorize the O Donnell Vein and Laser/Kelly O Donnell, M.D. to initiate a complaint or file an appeal to my insurance company and/or the insurance commissioner on my behalf and I personally will be active in the resolution of any claim delays, unjustified reductions or denials. Patient Signature: Date: Parent or Guardian Signature: Date:

6 Quality of Life Questionnaire Patient: Date: For each symptom, sensation or discomfort listed, please answer the corresponding question. Please circle the right answer. In the past four weeks, you have felt pain in the ankles or legs, what was the intensity of this pain? No Pain Light Pain Moderate Pain Strong Pain Intense Pain During the past four weeks, to what extent did you feel bothered/limited in your work or your other daily activities because of your leg problem? Not A Little Moderately Very Extremely During the past four weeks, did you sleep badly because of your leg problems, and how often? Never Seldom Fairly Often Very Often Every Night 166 Defense Highway Suite 101 Annapolis, MD FAX ANNAPOLIS EASTON ODonnellVeinandLaser.com

7 During the past four weeks, to what extent did your leg problems bother/limit you while doing the movements or activities listed below? To stand for a long time To climb stairs To crouch or kneel To walk briskly To travel by car, bus, plane To do housework such as standing in kitchen, carrying a child in your arms, cleaning floors or furniture, doing handy work To go to discos, weddings, parties, cocktails To play a sport, to make physically strenuous efforts Not Limited at All A Little Limited Moderately Limited Very Limited Impossible to do Leg problems can also have an effect on one s morale. To what extent do the following sentences correspond to the way you have felt during the past four weeks? I feel on edge I become tired quickly I feel I am a burden to people I must always take precaution (such as to stretch my legs, to avoid standing for a long time ) I am embarrassed to show my legs I get irritated easily I feel handicapped I have difficulty getting going in the morning I do not feel like going out Not at all A little Moderately A lot Absolutely

The Premier Vein Center Evan Oblonsky MD 1051 W. Rand Road, Suite 104 Arlington Heights, IL Tel: Fax:

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