Interventional and Vascular Consultants, PC P: F:

Transcription

1 Date: Patient Name: Date of Birth: / / Age: Sex: Male Female Referring Physician/Specialist: Varicose Vein Questionnaire 1. During the past 4 s, how often have you had the following leg problems? Heavy legs Everyday Several times a About once a Less than once a Aching legs Swelling Night Cramps Heat or burning sensation Restless legs Throbbing Itching Tingling sensation (ex/ pins and needle) 2. At what time of day is your leg problem most intense? (check one) On Waking During the night At mid-day At the end of the day At any time of day 3. Compared to one year ago, how would you rate your leg problem in general now? (check one) Much better now than one year ago Somewhat worse now that one year ago Somewhat better now than one year ago About the same now as one year ago Much worse now than one year ago I did not have any leg problems last year

2 Patient Name: Date of Birth: / / 4. The following items are about activities that you might do in a typical day. Does your leg problem now limit you in these activities? If so, how much? (Check one box per line) I do not work YES, Limited A Lot YES, Limited A Little NO, Not Limited at all Daily activities at work Daily activities at home (housework, ironing, doing odd jobs/repairs around the house, gardening, etc..). Social or leisure activities in which you are standing for long periods (parties, public transportation, shopping, etc ) Social or leisure activities in which you are sitting for long periods (going to the theater, traveling, etc ) 5. During the past 4 s, have you had any of the following problems with your work or other regular daily activities as a result of your leg problem? (check one box on each line) YES NO Cut down the amount of time you spent on work or other activities Accomplished less than you would like Were limited in the kind of work or other activities Had difficulty performing the work or other activities (for example, it took extra effort) 6. During the past 4 s, to what extent has your leg problem interfered with your normal social activities with family, friends, neighbors, or groups? (check one) Not at all quite a bit Slightly Extremely Moderately 7. How much leg pain have you had during the past 4 s? (check one) None Moderate Very mild Severe Mild Very severe

3 Patient Name: Date of Birth: / / 8. These questions are about how you feel and how things have been with you during the past 4 s as a result of your leg problem. For each question, please give the one answer that comes closest to the way you have been feeling. How much of the time during the past 4 s (check one box on each line) Have you felt concerned about the appearance on your leg(s)? Have you felt irritable? All of the time Most of the A Good Bit of the Some of the A Little of the None of the Have you felt a burden to your family or friends? Have you been worried about bumping into things? Has the appearance of your leg(s) influenced your choice of clothing? Patient Signature: Date:

4 25030 SW Parkway Ave. Ste. 200 Date: Patient Name: Date of Birth: / / Age: Sex: Male Female Referring Physician/Specialist: VEIN HISTORY QUESTIONNAIRE Have you had any prior treatment for varicose/spider veins? YES NO Date(s) of treatment Type of treatment(s) used, if known Do you have any history of ulcerations, clots in veins, or deep vein thrombosis? YES NO Do you have a family history of varicose/spider veins? YES NO If so, relationship(s) to you If female, are you currently, or have you been on any hormone therapy or birth control pills? YES NO If so, please list If female, have you had any pregnancies? YES NO If so, how many? Did your spider/varicose veins increase after your pregnancies? YES NO Do you wear support hose? YES NO If yes, are they prescription or over-the-counter (OTC)? RX OTC Are you presently employed? YES NO If so, why type of job? Do you sit or stand for long periods of time? YES NO How many hours per day? Do you take any pain medication for your varicose/spider veins (Aspirin/Tylenol/Anti-inflamitories? YES NO Do you elevate your legs to relieve your symptoms? YES NO If so, does it work? YES NO Do you have a history of hyperpigmentation or skin discoloration? YES NO Are you currently taking any of the following medications? Antipsychotics YES NO Antimalarials YES NO Cytotxic Drugs YES NO Amiodarone YES NO NSAIDS YES NO Tetrocycline YES NO

5 25030 SW Parkway Ave. Ste. 200 Patient Name: Date of Birth: / / Please check all those that apply Edema (swelling) Pain Tiredness Ulceration Skin Color Changes Spider Veins Varicose Veins Right Leg Left Leg What time of day is your leg problem most intense? (check one) On Waking During the night At mid-day At any time of day At the end of the day Compared to one year ago, how would you rate your leg problem in general now? (check one) Better than one year ago Worse than one year ago Same as one year ago The following items are activities you might do in a typical day. Does your leg problem limit you in these activities? Daily activities at work YES NO Daily activities at home (housework, odd jobs/repairs, gardening etc.) YES NO Social or leisure activities in which you are standing for long periods (parties, shopping etc.) YES NO Social or leisure activities in which you are sitting for long periods (going to the theater, traveling etc.) YES NO These questions are about how you feel and how things have been with you as a result of your leg problem. Have you felt concerned about the appearance of your legs(s)? YES NO Have you felt irritable? YES NO Have you felt a burden to family or friends? YES NO Have you been worried about bumping into things? YES NO Has the appearance of your leg(s) influenced your choice of clothing? YES NO Patient Signature: Date: