New Patient Vein Questionnaire

PERSONAL DETAILS

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MEDICAL DETAILS

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MEDICAL CONDITIONS

Heart Disease*
Thyroid Problems*
Osteoporosis*
High Blood Pressure*
Psychiatric Problems*
Low Blood Pressure*
Psychiatric Problems*
Lung Disease*
Sciatica*
AIDS or HIV Positive*
Arthritis*
Skin Problems*
Anaemia*
Diabetes*
Varicose Veins*
Bleeding Disorder*
Kidney Disease*
Menstrual Issues*
Easy Bruising*
Epilepsy*
Post-Surgery Dark Stains*

WOMEN ONLY

Are you pregnant?*
Are you breastfeeding?*
Do you have children?*
Are you on hormone replacement therapy?*
Are you taking birth control pills?*

FAMILY HISTORY

Does anyone in your family have varicose veins, leg ulcers or swollen legs?*
If yes, select all that apply:*

GENERAL MEDICAL QUESTIONNAIRE

Have you had surgery in hospital?*
Do you have any allergies?*
Are you taking any medication?*
Do you drink alcohol?*
Do you smoke*
Have you or a family member ever had a blood clot, Deep Vein Thrombosis (DVT) or Lung Clot?*
Are you under the care of a doctor?*

VEIN PROBLEM QUESTIONNAIRE

Did your veins develop post-injury?*
Have your veins deteriorated much?*
Do you elevate your legs for relief?*
Does plane travel affect your legs?*
Do you stand much at work?*
Do you experience pain when standing?*

VEIN SYMPTOMS

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

PREVIOUS VEIN TREATMENTS

Have you ever had a leg ultrasound for your veins?*
Have you had any previous ulcers?*
Have you had any clots in your legs or lungs?*
Have you ever had any of the following vein treatments? (Please tick)

COMMUNICATIONS

How did you find out about the DOC Clinic? (Please tick)
Are you happy to receive information via email from our practice?*

SIGNATURE

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

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