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info@kamloopsskinsolutions.com

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BEYOND BREAST CANCER
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CART

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Vein ConsultationJennifer Cook2024-07-08T18:02:19-07:00

Vein Consultation Client Form

Vein Consultation PDF Form

If you choose the PDF option, print and complete the form at home and bring it with you to your appointment. Or scan your completed form and email it to us at info@kamloopsskinsolutions.com before you visit the clinic.

RETURN TO > BEFORE YOUR APPOINTMENT

Please use this simple and secure online form which is signed electronically and sent directly to us immediately upon completion.

Name *

First

Last

Personal Health Number *

Birthdate *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Phone Number to Reach You *

Permission to contact you for appointment reminders by text? *

Email Address

Emergency Contact & Relationship *

Emergency Contact Phone *

Family Physician

Your Occupation

Current Medications

Previous Surgeries

Drug Allergies

Latex Allergy? *

Height *

Weight. Please indicate lbs or kgs. *

How did you hear about us?

Word of mouth
Friend/client here
Instagram
Google/website
Facebook
Other

If other, please specify:

Lifestyle

Cigarettes? *

Cigarettes per day

Years smoked

Alcohol/drinks per week *

Exercise frequency per week *

Personal History

Heart disease
Seizures
Hypertension
Diabetes
Bleeding problems
Previous stroke/TIA
Cancer
Thyroid problems
Migraines
Other (please list in space provided)

If you chose "other", please list conditions

Have you ever been documented to be a carrier of an antibiotic resistant organism (ARO)? *

Symptoms Related to Venous System

DISCOMFORT

Discomfort in Right Leg *

None
Occasional
Daily
Daily – limits activity

Discomfort in Left Leg *

None
Occasional
Daily
Daily – limits activity

EDEMA/SWELLING

Edema/Swelling in Right Leg *

None
Foot/Ankle
Above ankle to knee
Above knee

Edema/Swelling in Left Leg *

None
Foot/Ankle
Above ankle to knee
Above knee

SKIN CHANGES OR ULCER

Skin Changes or Ulcer in Right Leg *

Skin Changes or Ulcer in Left Leg *

PREVIOUS VENOUS TREATMENT

Previous Venous Treatment in Right Leg *

None
Sclerotherapy
Surgery
EVLT – Endovenous Laser
Laser for Spiders

Previous Venous Treatment in Left Leg *

None
Sclerotherapy
Surgery
EVLT – Endovenous Laser
Laser for Spiders

INVESTIGATIONS

Investigations in Right Leg *

None
Superficial Mapping
Vascular Lab

Investigations in Left Leg *

None
Superficial Mapping
Vascular Lab

PREVIOUS DVT

Previous DVT in Right Leg *

Previous DVT in Left Leg *

Compression Therapy

Do you wear compression stockings?

Daily?

Reason:

For treatment
For compression

Personal & Family History

Heart abnormalities – VSD or ASD *

None
Personal
Family

Bleeding or clotting disorder *

None
Personal
Family

Varicose veins *

None
Personal
Family

Have you ever been told you need antibiotics for dental procedures? *

Pulmonary Embolus *

None
Personal
Family

Signature *

Clear Signature

Date

Name