Laser Vein Center Thomas Wright MD RVT Page 1 of 4

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Laser Vein Center Thomas Wright MD Page 1 of 4

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Transcription:

Demographics Laser Vein Center Thomas Wright MD RVT Page 1 of 4 Patient Name: Address: City, St, Zip Primary Phone: Alternate: DOB: Social Security #: Marital Status: Married Single Other Emergency Contact: Emergency #: Relationship: Employer/ School _ Occupation: Which number would you prefer us to leave a message: Home Cell Work Do we have your permission to send you a birthday card, a holiday card or perhaps a newsletter to your Home Email Email: Referring Source: Family Doctor Phone # Are you currently being treated by any other physician(s)? No Yes (If Yes; Please list with phone number) List of Medications (below) Dosage How Often Taken Name of Pharmacy Phone # _ List ALL Allergies Surgeries & Dates:

Laser Vein Center Thomas Wright MD RVT Page 2 of 4 Mark any of the following conditions you or a family member has EVER experienced? Condition Self Family Please Explain Sinusitis Hypothyroidism Skin cancer Abnormal moles Psoriasis Eczema Hives Asthma COPD Lung cancer Pneumonia Atrial fibrillation Murmur Angina (chest pain) Ankle swelling Heart attack High blood pressure Rheumatic/Scarlet fever Gastric reflux (GERD) Gastric bleeding Colon cancer Prostate/cancer enlargement Testicular cancer Pinched nerve Spinal stenosis Stroke/seizures/TIA Diabetes (type) Breast cancer Anemia

Change in weight High blood pressure High cholesterol Fatigue Fevers Cancer Decreased vision Double vision Temporary blindness Blurred vision Detached retina Temporal arteritis Paralysis Weakness Seizure Fainting Headache Migraine Stroke Numbness in limbs Slurred speech Decreased memory Ankle swelling Atrial fibrillation Labored breathing Dizziness Congenital heart dis. Rheumatic heart dis. Murmur Loss of consciousness Palpitations Chest pain Chest discomfort Unable to urinate Painful urination Prostate problems Kidney/bladder dis. Decr. urine stream Kidney failure Blood in urine Excessive urination Laser Vein Center Thomas Wright MD RVT Are you pregnant? No Yes Number of Pregnancies Number of Births Decreased appetite Anxiety Cough Confusion Depression Delusions Easy bruising Anemia Clotting disorder Bleeding disorder Pain in leg at rest Leg pain when walking Slow healing leg wound Sensitivity to cold Arterial disease History of gangrene Change in moles Itching Rash Dry skin Chronic skin problems Sore throat Sinus drainage Hoarseness Discharge from ears Nose bleeds Hearing loss Ringing in ears Painful swallowing Indigestion Vomiting Vomiting blood Gall bladder problems Liver disease Hemorrhoids Diarrhea Jaundice Constipation Abdominal pain Bloody stools Change in stool color Change in bowel habits Respiratory pain COPD Prod. of sputum Coughing blood Apnea Wheezing Bronchitis Pneumonia Bone/joint deformity Joint swelling Back pain Muscle aches Limited motion Knee replacement Hip replacement Spinal problems Thyroid disorder Diabetes w/ insulin Diabetes -no insulin Extreme appetite Extreme thirst Lupus Rheumatoid arthritis FEMALE ONLY Irregular periods Breast problems Menopause Last pelvic exam Last period OFFICE USE ONLY Page 3 of 4 No mo / year year

Laser Vein Center Thomas Wright MD RVT Page 4 of 4 Habits Do you drink alcoholic beverages? No Yes (#/week ) Do you now or have you ever used tobacco? No Yes (Packs/week )Quit Date, if applicable Do you exercise regularly? No Yes (#of days / week ) Vein History When did you first notice your enlarged or discolored veins? Where are the veins you are seeking a medical opinion for located? Face Leg(s), (Circle) Right Leg / Left Leg / Both Have you ever worn prescription grade compression stockings?, When and for how long? Do you have a family history of vein problems?, What family member? Please next to the symptoms that apply to you: Aching leg(s) Appearance Burning Cramps Dull Pain Heaviness Itching Leg Ulcers Restless Legs Sharp Pain Swelling Throbbing Tiredness Other: Phlebitis (Clot in surface veins in legs)?, When Deep Vein Thrombosis (Clot in deep veins)?, When Pulmonary Embolus (Blood clot in lungs)?, When Bleeding from veins?, When Have you had sclerotherapy before?, When Venogram (Vein X-Ray), When Have you ever had vein surgery?, When Hemorrhoids?, When IV drug use?, When AIDS/HIV/hepatitis?, When Trauma/injury to your legs?, When Clotting disorder?, When I request that payment of authorized Medicare/third party insurers benefits be made either to me or on my behalf to Dr. Thomas Wright for any services furnished by me. I authorize any holder of medical or other information about me to release to the Centers of Medicare & Medicaid Services or third party insurer or their agents any information needed to determine these benefits or benefits for related services. I understand I am responsible for any balance not covered by my insurer. Patient Signature Date

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