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161 East Mallard Drive, Suite 130, Boise, ID 83706 (208) 947-0100 New Patient Intake Patient Name: Primary Care Physician: Date: Email address: How did you hear about AVT (mark all that apply) Online On the radio Website In print On TV Providers office Previous Patient Family/Friend Other Describe your main complaint (i.e., symptoms you are experiencing such as leg pain, swelling, itching, etc.): Please describe, in detail, when the symptoms began: _ Is there anything that makes your symptoms worse? (i.e., standing for a prolonged period of time)? Is there anything that improves your symptoms (i.e., elevating your legs)? When you have prescriptions filled, which pharmacy do you use? Please answer the following questions as completely as possible. Have you had previous treatment for spider or varicose veins?......................... Yes o If so, please list the year, procedure performed, and treating physician: Have you had any ultrasound exams on your legs?....................................yes If so, please list the year and which hospital/radiology facility completed the scan: 1

Do you have a history of skin ulcerations thought to be due to vein disease?............. Yes Do you have a history of blood clots involving the superficial veins (aka SVT)?............ Yes Do you have a history of blood clots involving the deep veins? (aka DVT)?............... Yes Do you have a history of pulmonary embolism (also known as PE)?..................... Yes Have you ever been diagnosed with a blood clotting disorder?......................... Yes Have you ever had an episode of bleeding from a ruptured superficial varicose vein?... Yes o If so, describe: Do you have a history of migraine headaches? with aura without aura........ Yes If yes, how many migraines per month: Do you have a family history of varicose veins?..................................... Yes o If so, who in your family is affected? Do you currently take hormones or birth control pills?................................ Yes Does your occupation require you to sit or stand for long periods?..................... Yes o If so, please describe (example: hairdresser for 20 years): Employer: Occupation: Do you exercise on a regular basis? If so, how many days per week? 1 2 3 4 5 6 7 o Please describe form of exercise : Do you or have you ever worn prescription graduated compression stockings?.......... Yes o If so, how many months or years have you been wearing them? Do you elevate your legs to relieve the discomfort (i.e., use a reclining chair)?............ Yes o How many days per week? 1 2 3 4 5 6 7 o For how many months/ years? _ Do you ever take over-the-counter medication to relieve leg pain?...................... Yes o Which medications have you tried (i.e ibuprofen, Tylenol)? Have any of these treatments relieved your symptoms?............................... Yes Pregnancies? Deliveries? Did your symptoms increase during pregnancy? Yes 2

Please rate your pain severity on each leg below from 1-10 (10 being the worse) RIGHT LEG LEFT LEG Pain 1-10 Pain 1-10 Please mark an X by the symptoms you are experiencing Aching Throbbing Stinging Burning Swelling Cramping (Charlie horse) Leg feels tired Leg feels heavy Ulcer (wound) Skin discoloration Itching Numbness or tingling Restless leg Aching Throbbing Stinging Burning Swelling Cramping (Charlie horse) Leg feels tired Leg feels heavy Ulcer (wound) Skin discoloration Itching Numbness or tingling Restless leg Anterior (front of legs) Posterior (back of legs) Rt Lt Lt Rt Activities of Daily Living Does leg pain make it difficult to fall asleep at night? yes no Stay asleep at night? yes no Do restless legs make it difficult to fall asleep at night? yes no Do you ever have night-time leg cramps that wake you up? yes no Do you ever need to elevate your legs as soon as you arrive home, thus delaying preparation of dinner? yes no Do you find it is difficult to stand while cooking or washing dishes? yes no Are there any chores at home that are now difficult to perform due to leg pain, etc.? yes no Does leg fatigue or heaviness make it difficult to walk up stairs? yes no Do you find yourself protecting or guarding your lower leg(s) when around small children or dogs? yes no 3

Patient Medical History Allergies and reaction: Current Medications Medication Dosage (mg) Frequency Hospitalizations and/or Surgeries Surgery / Reason for Hospitalization Year Adult Illnesses do you have a personal history of any of the conditions listed below? Cardiovascular Disease High Blood Pressure High Cholesterol Cancer Tuberculosis Diabetes Thyroid Disease Arthritis Asthma Other recurring disease: Family History - do any of your family member have a history of any of the conditions listed below? Cardiovascular Disease High Blood Pressure High Cholesterol Cancer Tuberculosis Diabetes Thyroid Disease Arthritis Asthma Other recurring disease: Social History Employer: Retired? if yes, how many years? Married years Single Divorced Smoke currently or ever? yes no if yes, how many years? Alcohol use IV drug use 4

Review of Systems Please check those that apply General Appetite change Fatigue Fever Chills describe: Skin Rashes Itching describe: Eyes Blindness Decreased vision Blurred vision Double vision Eye pain describe: Ear,se,Throat Dizziness Ringing in ears Decreased hearing se bleeds Hoarseness Dental problems Difficulty swallowing describe: Cardiorespiratory Chest pain Palpitations Heart murmur Fainting Cough Bloody sputum Wheezing Difficulty breathing Sleep apnea describe: Gastrointestinal Nausea Vomiting Blood in vomit Diarrhea Constipation Blood in stool Abdominal pain describe: Genitourinary Urinary incontinence Burning with urination Blood in urine describe: Musculoskeletal Joint pain Muscle pain Difficulty walking Leg cramping describe: Endocrine Temperature intolerance Weight change Menstrual change Skin change Hair change describe: Neurologic Headaches Tremor Seizures Numbness/tingling describe: Psychiatric Depression Anxiety describe: Hematologic Clot in the deep veins Blood clotting disorder Transfusions describe: Allergic/Immune Infection Hives Anaphylaxis describe: By signing this I agree that the information supplied by me is accurate and complete to the best of my knowledge. Patient Signature: Date: NewPatientIntake 8-2015.docm 5

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