New Patient Vein Questionnaire

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PERSONAL DETAILS

Full Name*

Date of Birth*

DD slash MM slash YYYY

Full Address*

Email Address*

Home Phone

Work Phone

Mobile Phone*

Emergency Contact Name*

Emergency Contact Phone*

MEDICAL DETAILS

Medicare Number*

Expiry Date*

Medicare Number Next to Name*

Family Doctor’s Name*

Doctor’s Practice Address*

Doctor’s Phone Number*

MEDICAL CONDITIONS

Heart Disease*

Yes

No

Thyroid Problems*

Yes

No

Osteoporosis*

Yes

No

High Blood Pressure*

Yes

No

Psychiatric Problems*

Yes

No

Low Blood Pressure*

Yes

No

Lung Disease*

Yes

No

Sciatica*

Yes

No

AIDS or HIV Positive*

Yes

No

Arthritis*

Yes

No

Skin Problems*

Yes

No

Anaemia*

Yes

No

Diabetes*

Yes

No

Varicose Veins*

Yes

No

Bleeding Disorder*

Yes

No

Kidney Disease*

Yes

No

Menstrual Issues*

Yes

No

Easy Bruising*

Yes

No

Epilepsy*

Yes

No

Post-Surgery Dark Stains*

Yes

No

Other (please elaborate)

WOMEN ONLY

Are you a woman?*

Yes

No

Are you pregnant?*

Yes

No

Are you breastfeeding?*

Yes

No

Do you have children?*

Yes

No

If yes, how many children?*

Do you intend to have more?*

Are you on hormone replacement therapy?*

Yes

No

Are you taking birth control pills?*

Yes

No

If yes, what is the name of your medication?*

FAMILY HISTORY

Does anyone in your family have varicose veins, leg ulcers or swollen legs?*

Yes

No

If yes, select all that apply:*

Mother

Father

Sister

Brother

Children

GENERAL MEDICAL QUESTIONNAIRE

Have you had surgery in hospital?*

Yes

No

If yes, when and why?*

Do you have any allergies?*

Yes

No

If yes, please specify and describe reactions*

Are you taking any medication?*

Yes

No

If yes, then please list?*

Do you drink alcohol?*

Yes

No

If yes, how much per week?*

Do you smoke*

Yes

No

If yes, how many per day?*

Have you or a family member ever had a blood clot, Deep Vein Thrombosis (DVT) or Lung Clot?*

Yes

No

If yes, please specify:*

Are you under the care of a doctor?*

Yes

No

VEIN PROBLEM QUESTIONNAIRE

How long have you had vein issues?*

Did your veins develop post-injury?*

Yes

No

Have your veins deteriorated much?*

Yes

No

Do you elevate your legs for relief?*

Yes

No

Does plane travel affect your legs?*

Yes

No

Do you stand much at work?*

Yes

No

Do you experience pain when standing?*

Yes

No

If yes, what problems do you experience?*

VEIN SYMPTOMS

Do you experience any of the following symptoms in your legs? (Please tick)

Aching Pain

Tiredness

Walking Pain

Discomfort

Cold Feet

Swollen Ankles

Leg Cramps

Heaviness

Itching

Other

Burning Sensation

Tenderness

Throbbing

Restlessness in the Legs

PREVIOUS VEIN TREATMENTS

Have you ever had a leg ultrasound for your veins?*

Yes

No

Have you had any previous ulcers?*

Yes

No

Have you had any clots in your legs or lungs?*

Yes

No

Have you ever had any of the following vein treatments? (Please tick)

Surgery

Laser

Electro-cautery

Injections (sclerotherapy)

COMMUNICATIONS

How did you find out about the DOC Clinic? (Please tick)

The DOC Website

Google

Facebook

Twitter

Via Email

Referred by a friend

Existing patient of Ed

Other

Referred by a friend

Existing patient of Ed (which clinic?)

Other (please elaborate)

Are you happy to receive information via email from our practice?*

Yes

No

Preferred email address (if different from top)*

SIGNATURE

I have answered this questionnaire to the best of my ability:

Print full name*

Signed

Dated*

DD slash MM slash YYYY

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