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VISIT US TODAY AT
302 Heaths Road, Hoppers Crossing, Victoria 3029
New Patient Vein Questionnaire
Home
About Us
About Dr Ed Omarjee
Our Facilities
Our Devices
CPCA certification
Payment Options
We’re in the News!
Concerns
Acne
Acne Medical Management
Carbon Facial
Cosmeceutical Skin Care
Healite II
Acne Scarring
Fotona Laser Resurfacing
Cosmeceutical Skin Care
Facial Volume Treatment
Twinlight Fractional Rejuvenation
Fraxel Laser Treatments
Laser Genesis
Regen PRP
Secret RF
Skin Needling
Excessive Sweating
Anti-Wrinkle Injections
Fat Reduction
Fotona Tightscupting
Jaw Grinding (Bruxism)
Anti-Wrinkle Injections
Keloid & Hypertrophic Scars
Loose Skin/ Skin Tightening
Fotona Tightlase
Fotona 4D Non-Surgical Facelift
Facial Volume Treatment
Secret RF
Ultraformer 3 (HIFU)
Migraines
Injectable Migraine Treatment
Moles
Excisional Mole and Skin Lesion Biopsy
Laser Mole Removal
Radio Frequency Mole Removal
Red Face (Rosacea)
Cosmeceutical Skin Care
Healite II
Laser Genesis
Scars
Facial Volume Treatment
Effective Keloid Scar Removal Treatment
Fraxel 1550nm
Fotona Laser Resurfacing
Laser Genesis
Regen PRP
Secret RF
Skin Pigmentation
Age Spots / Freckles / Sun Damage
Cosmeceutical Skin Care
Fotona Resurfacing
Square Jaw
Facial Slimming
Under Eye Wrinkles
Anti-wrinkle Injections
Cosmeceutical Skin Care
Fotona Laser Resurfacing
Laser Genesis
Regen PRP
Secret RF
Skin Needling
Smooth Eye
Ultraformer 3
Upper Lip Lines
Fotona Laser Resurfacing
Anti-wrinkle Injections
Cosmeceutical Skin Care
Facial Volume Treatment
Fraxel Laser Treatments
Laser Genesis
Regen PRP
Secret RF
Ultraformer 3
Unwanted Tattoos
Laser Tattoo Removal
Veins
Facial Veins
Laser Haemangioma Treatment
Laser Rosacea Treatment
Laser or Micro Sclerotherapy Spider Leg Veins
Ultrasound Guided Foam Sclerotherapy For Varicose Veins
Visible Gums
Injectable Gummy Smile Treatment
Wrinkles
Anti-wrinkle Injections
Cosmeceutical Skin Care
Facial Volume Treatment
Fotona Resurfacing
Fraxel Laser Treatments
Laser Genesis
Regen PRP
Smooth Eye
Secret RF
Skin Needling
Ultraformer 3
Xanthelasma (Yellow Ocular Lesions) Treatment
Cosmetic & Skin Treatments
Cosmetic Injectables
Wrinkle Treatments
Facial Volume Treatment
Lip Volume Treatment
Facial Slimming
Gummy Smiles
Hyperhidrosis
Migraine Management
Regen PRP
Clarius LD20 Facial Ultrasound Scanner
Fat Reduction & Skin Tightening
Fotona Tightsculpting
Facials
Carbon Facial
Laser Treatments
Fotona Laser
Fotona Laser Resurfacing
Fotona 4D Rejuvenation
Fotona Smooth Eye
Nightlase (Non-surgical snoring therapy)
Fotona Skin Tightening
Fotona TightSculpting
Twinlight Laser Rejuvenation
FRAC3 Rejuvenation
PIANO Rejuvenation
Fraxel Laser Rejuvenation
Laser Genesis (collagen stimulation therapy)
Laser Mole Removal
Tattoo Removal
Facial Veins Laser Treatment
Cutera Excel V Plus
Medical LED Therapy
Healite II
Medical
Acne Scarring
Acne Medical Management
Excisional Mole and Skin Lesion Biopsy
Keloid Scar Removal
Xanthelasma Treatment
Laser Facial Vein Treatment
Laser Haemangioma Treatment
Laser Rosacea Treatment
Laser or Micro Sclerotherapy Spider Leg Veins
Ultrasound Guided Foam Sclerotherapy For Varicose Veins
Skin Needling
MDerma and Dermapen
Secret RF
Skin tightening/Lifting
Fotona Tightlase
Ultraformer 3
HIFU and RF
Secret RF
Ultraformer 3
RF Mole removal (Cosmetic Mole Removal)
Prices & Promotions
Vein Treatment Prices
Keloid & Acne Scar Treatment Prices
Injectable Prices
Cosmetic Mole & Skin Lesion Removal Prices
Case Studies
Gallery
Blog
Contact Us
Search for:
Search Button
Home
About Us
About Dr Ed Omarjee
Our Facilities
Our Devices
CPCA certification
Payment Options
We’re in the News!
Concerns
Acne
Acne Medical Management
Carbon Facial
Cosmeceutical Skin Care
Healite II
Acne Scarring
Fotona Laser Resurfacing
Cosmeceutical Skin Care
Facial Volume Treatment
Twinlight Fractional Rejuvenation
Fraxel Laser Treatments
Laser Genesis
Regen PRP
Secret RF
Skin Needling
Excessive Sweating
Anti-Wrinkle Injections
Fat Reduction
Fotona Tightscupting
Jaw Grinding (Bruxism)
Anti-Wrinkle Injections
Keloid & Hypertrophic Scars
Loose Skin/ Skin Tightening
Fotona Tightlase
Fotona 4D Non-Surgical Facelift
Facial Volume Treatment
Secret RF
Ultraformer 3 (HIFU)
Migraines
Injectable Migraine Treatment
Moles
Excisional Mole and Skin Lesion Biopsy
Laser Mole Removal
Radio Frequency Mole Removal
Red Face (Rosacea)
Cosmeceutical Skin Care
Healite II
Laser Genesis
Scars
Facial Volume Treatment
Effective Keloid Scar Removal Treatment
Fraxel 1550nm
Fotona Laser Resurfacing
Laser Genesis
Regen PRP
Secret RF
Skin Pigmentation
Age Spots / Freckles / Sun Damage
Cosmeceutical Skin Care
Fotona Resurfacing
Square Jaw
Facial Slimming
Under Eye Wrinkles
Anti-wrinkle Injections
Cosmeceutical Skin Care
Fotona Laser Resurfacing
Laser Genesis
Regen PRP
Secret RF
Skin Needling
Smooth Eye
Ultraformer 3
Upper Lip Lines
Fotona Laser Resurfacing
Anti-wrinkle Injections
Cosmeceutical Skin Care
Facial Volume Treatment
Fraxel Laser Treatments
Laser Genesis
Regen PRP
Secret RF
Ultraformer 3
Unwanted Tattoos
Laser Tattoo Removal
Veins
Facial Veins
Laser Haemangioma Treatment
Laser Rosacea Treatment
Laser or Micro Sclerotherapy Spider Leg Veins
Ultrasound Guided Foam Sclerotherapy For Varicose Veins
Visible Gums
Injectable Gummy Smile Treatment
Wrinkles
Anti-wrinkle Injections
Cosmeceutical Skin Care
Facial Volume Treatment
Fotona Resurfacing
Fraxel Laser Treatments
Laser Genesis
Regen PRP
Smooth Eye
Secret RF
Skin Needling
Ultraformer 3
Xanthelasma (Yellow Ocular Lesions) Treatment
Cosmetic & Skin Treatments
Cosmetic Injectables
Wrinkle Treatments
Facial Volume Treatment
Lip Volume Treatment
Facial Slimming
Gummy Smiles
Hyperhidrosis
Migraine Management
Regen PRP
Clarius LD20 Facial Ultrasound Scanner
Fat Reduction & Skin Tightening
Fotona Tightsculpting
Facials
Carbon Facial
Laser Treatments
Fotona Laser
Fotona Laser Resurfacing
Fotona 4D Rejuvenation
Fotona Smooth Eye
Nightlase (Non-surgical snoring therapy)
Fotona Skin Tightening
Fotona TightSculpting
Twinlight Laser Rejuvenation
FRAC3 Rejuvenation
PIANO Rejuvenation
Fraxel Laser Rejuvenation
Laser Genesis (collagen stimulation therapy)
Laser Mole Removal
Tattoo Removal
Facial Veins Laser Treatment
Cutera Excel V Plus
Medical LED Therapy
Healite II
Medical
Acne Scarring
Acne Medical Management
Excisional Mole and Skin Lesion Biopsy
Keloid Scar Removal
Xanthelasma Treatment
Laser Facial Vein Treatment
Laser Haemangioma Treatment
Laser Rosacea Treatment
Laser or Micro Sclerotherapy Spider Leg Veins
Ultrasound Guided Foam Sclerotherapy For Varicose Veins
Skin Needling
MDerma and Dermapen
Secret RF
Skin tightening/Lifting
Fotona Tightlase
Ultraformer 3
HIFU and RF
Secret RF
Ultraformer 3
RF Mole removal (Cosmetic Mole Removal)
Prices & Promotions
Vein Treatment Prices
Keloid & Acne Scar Treatment Prices
Injectable Prices
Cosmetic Mole & Skin Lesion Removal Prices
Case Studies
Gallery
Blog
Contact Us
Search for:
Search Button
Home
-
New Patient Vein Questionnaire
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
CAPTCHA
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