Patient Form

DOB:

Are you experiencing any of the following symptoms?

  • Pain
  • Heaviness
  • Cramping
  • Swelling
  • Numbness
  • Tingling
  • Burning Sensation
  • Discoloration
  • Skin Breakdown
  • Itching
Is one leg worse than the other?

Have you been treated for this problem before?

If yes, by whom and when?

Type of treatment received?

If "other", which?

Do you have a personal history of any of the following or are you being treated for:
  • Asthma
  • Thyroid
  • Heart Disease
  • Diabetes
  • High Blood Pressure
  • Rheumatic Fever
  • Phlebitis (clots in legs)
  • Deep Vein Thrombosis
  • Leg or Ankle Ulcers
  • Pulmonary Embolism
  • Seizures
  • Hepatitis
  • Leg Fracture or Trauma
  • Problems with Anesthesia
  • Autoimmune Disease (Lupus)
  • Cheloid Scarring
  • Blood Transfusions
  • HIV
List all past surgical procedures:
1.
Date of Surgery:
2.
Date of Surgery:
3.
Date of Surgery:
4.
Date of Surgery:
Other hospitalizations? (other than surgery or childbirth)

Are you taking any medications? (if yes please list):

1.
Dose:
2.
Dose:
3.
Dose:
4.
Dose:
Drug Allergies?

If yes, please list:

Is your skin sensitive to adhesive tape?

Are you allergic to latex?

Is there a family history of::

Height
Weight
What type of exercise do you do and how often?
Do you smoke?

If yes, how much?:
How were you referred to our office?
Are you under the care of a physician?

Whom?
Address
Phone Number
Date of your last visit:

May we send a medical report to your primary or referring physician?

Is there any other information you would consider pertinent to your treatment?

For Women:

Number of Pregnancies:

Are you pregnant now?

Are you breast feeding?

Number of Children:

General Information:

Phone Number

Email

Give us a date in which we can contact you:
Date:

Hour:

Do you want to schedule an appointment?