Form PT Assessment Rev 3/03//17 PATIENT ASSESSMENT DATE OF CONSULTATION: NAME: DATE OF BIRTH: SSN: SEX: M F HEIGHT: WEIGHT: REFERRED BY: WHICH LEG ARE YOUR COMPLAINTS LOCATED IN? (check one) Right Left Both HOW WOULD YOU DESCRIBE YOUR SYMPTOMS? (check all that apply) Aching Edema Tenderness Awakened at night Fatigue Throbbing Bleeding from veins Heaviness Ulcers Bulging Itching Varicose Veins Burning Painful Spider Veins Cramping Restless Legs Skin discoloration Difficulty healing wounds Swelling Other: WHERE ARE YOUR SYMPTOMS LOCATED? (check one) Whole Leg Thigh Knee Calf Ankle Buttocks Groin Other: HOW WOULD YOU RATE THE SEVERITY OF YOUR SYMPTOMS? (check one) Mild Moderate Severe HOW LONG HAVE YOUR SYMPTOMS BEEN BOTHERING YOU? (fill in a number) weeks months years DO YOU HAVE ULCERS? YES NO WHICH LEG? RIGHT LEFT IF YES, HOW LONG HAVE YOU HAD THEM? RIGHT LEG: days months years N/A LEFT LEG: days months years N/A 1
Form PT Assessment Rev 3/03/17 WHEN DO YOUR SYMPTOMS OCCUR? CHOOSE THE BEST ANSWER BELOW. (check one) Mostly at nighttime All day Only during the day While laying down At bedtime Other: ARE YOUR SYMPTOMS WORSE IN ONE LEG THAN THE OTHER? (check one) Worse in the right leg Worse in the left leg Equal in both legs DO YOUR SYMPTOMS AFFECT YOUR ACTIVITIES OF DAILY LIVING? If yes, which activities are affected: (check all that apply) Yes or No Exercise Unable to stand Long Sex life Unable to walk hills Unable to sit long Travel Walking long distances Unable to work Sleep / Relaxation Walking short distances Homemaking Other: ARE YOUR SYMPTOMS WORSENED BY: (check all that apply) Prolonged Standing Walking Heat Premenstrual Travel Working Prolonged Sitting Exercise Hot Bath Pregnancy Resting Other: PLEASE MARK ANY CONSERVATIVE THERAPY MEASURES THAT YOU HAVE TRIED IN THE PAST TO RELIEVE YOUR SYMPTOMS: (check all that apply) Compression stockings Weight reduction Cold soak Walking Leg elevation Avoid prolonged sitting Warm soak Pain medications Exercise Avoid prolonged standing Other: If yes to compression stockings: Compression How Long? Worn When? Store bought weeks Night Only Exercising Prior EVLA 20-30 mm Hg months All Day Traveling Prior Sclero 30-40 mm Hg years Working Prior Surgery 2
Form PT Assessment Rev 3/03/2017 If yes to pain medications: (check all that apply) Rx Meds Aleve Ibuprofen Tylenol Aspirin HOW OFTEN HAVE YOU USED MEDICATION? (check all that apply) Hourly Daily Weekly Monthly 0-2 days/wk 3-4 days/wk 5-6 days in 2 wk period 7 > days in 2 wk period WAS THERE RELIEF FROM SYMPTOMS WITH THE ABOVE CONSERVATIVE THERAPY MEASURES? Yes No HAVE YOU HAD ANY VEIN TREATMENTS PERFORMED IN THE PAST? Yes or No If yes, please list them below: Previous Treatments: Circle Year Doctor Sclerotherapy/Injections Right / Left High Flush Ligation Right / Left Phlebectomy/Stripping Right / Left Percutaneous Ligation Right / Left EVLA / Venous Closure (circle one) Right / Left Treatment for leg cramps Treatment of ulcers, phlebitis, cellulitis or edema Type: Type: PAST MEDICAL HISTORY: (check all that apply) Phlebitis Trauma/Injury to Leg Muscular Disease Varicose Veins Migraine Headaches Hormonal Therapy Spider Veins Asthma Diabetes Bleeding Veins Mitral Valve Prolapse Seizures Leg Ulcers Arrhythmia Cancer: Leg Swelling/Edema CVA/Stroke Back Inj./Pain/Discomfort Blood Clots Hypertension Hepatitis Arterial Disease/Blockage Heart Problems Liver Disease Currently Pregnant/Planning HIV/AIDS Kidney Disease Bleeding Disorder Arthritis Hyper/Hypothyroidism Aneurysm Other: 3
Form PT Assessment REV 3/03/2017 PAST SURGICAL HISTORY: (check all that apply) Adenoidectomy Lung Resection Breast Biopsy/Mastectomy Skin Cancer Colon Resection Hernia Repair Hip Replacement Breast Augmentation Appendectomy Prostate Knee Replacement Tummy Tuck Gall Bladder Hysterectomy Thyroid Surgery Liposuction C-Section Tubal Ligation Tonsillectomy Face Lift Bypass Other: Any surgical complications? FAMILY HISTORY OF VARICOSE VEINS? Yes or No If yes, which family members: (check all that apply) Mother Father Siblings Grandmother Grandfather FAMILY HISTORY OF CLOTTING DISORDER? Yes or No If yes, which family members: (check all that apply) Mother Father Siblings Grandmother Grandfather PLEASE SELECT YOUR CURRENT EMPLOYMENT STATUS Retired Unemployed Full-time Part-time Self-employed Homemaker SMOKING STATUS: Current every day smoker Current some day smoker Former smoker Never smoked If you are a current or former smoker, how many packs per day? How long did you smoke regularly? years At what age did you start smoking? years HOW MANY PREGNANCIES HAVE YOU HAD? (number) HOW MANY CHILDREN HAVE YOU HAD? (number) 4
Form PT Assessment Rev 3/03/2017 PLEASE LIST ALL ALLERGIES: PLEASE LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING: (including Herbs, Vitamins, Supplements, etc.) NAME OF MEDICATION STRENGTH REASON YOU ARE TAKING PLEASE MARK ANY ADDITIONAL SYMPTOMS YOU ARE EXPERIENCING TODAY OR RECENTLY: Fatigue Hemorrhoids Anxiety Fever Indigestion Depression Recent Weight Loss Jaundice Insomnia Recent Weight Gain Pain on Defecation Mood Swings Decreased Vision Rectal Bleeding Blood in Urine Disturbance of Vision Vomiting of Blood Difficulty Passing Urine Loss of Vision Joint Pain Irregular Periods Chest Pain Leg Cramps Pain/Burn Urination Palpitations Night Cramps Pain w/intercourse Shortness of Breath While Walking Easy Skin Bruising Pain w/menstruation Shortness of Breath While Lying Flat Eczema Pelvic Pain 5
Form PT Assessment Rev 5/31//16 Swelling of Legs & Ankles Hair Loss Vulvar/Vaginal Veins Varicose Veins Heavy Sweating Cold Intolerance Deep Vein Thrombosis (DVT) Skin Itching Excessive Thirst Phlebitis Skin Rashes Excessive Urination Wounds in Lower Extremity Skin Lesions Heat Intolerance Cold Sores Ulcers Incontinence Hoarse Voice Difficulty Speaking Bleeding Tendency Sinus Problems Abnormal Numbness Enlarged Lymph Nodes Sore Throat Dizziness Clot/Bleed Disorder Chronic/Frequent Cough Drooping of the Face Allergic Hives Cough/Spit Up Blood Frequent Headaches Allergic Itching Wheezing Fainting Spells Allergic Rashes Abdominal Pain Involuntary Moment Recurring Infections Black Tarry Stools Leg Weakness Change in Bowel Habits Migraines Difficulties/Painful Swallowing Needle Phobia Heartburn Nervousness Other: