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Dr Lisa MarksLevel 4, 18 North TerraceAdelaide SA 5000Ph 08 8213 1800
MEDICAL HISTORY QUESTIONNAIRE
LEG VEIN ASSESSMENT
Please take a few minutes to answer the following questions carefully as this assists us in preparing foryour assessment. The information from this Questionnaire may be used for research purposes. Your personal details will be withheld. Please tick what is correct. If you are not sure about the answer,leave it blank and ask the doctor at your consultation.
Surname . First name . Your current complaint
Are you consulting for? (Please circle)
a. Varicose veins of the legsb. Spider veins of the legs
d. Recurrence of the veins after an operation
e. Recurrence of the veins after injections
a. Pain in your legs
c. Bursting pain in the calf after exercise
If you experience pain in your legs:
1. Does your pain get worse:
a. before your menstrual periods
2. Do the symptoms get better with:
Onset of Veins
When did your veins occur? (Please circle)
a. Age: .
b. Since childhood
c. After taking the contraceptive pill
d. Before pregnancy
e. During pregnancy
f. After pregnancy (while breast feeding).
g. After menopauseh. After an operationi. After traumaOther.
Ladies only: Do you suffer from:
a. Heaviness in the lower abdomen
Past Venous History
Have you had any of the following:
a. Phlebitis (inflammation of a vein)
c. Pulmonary embolism (blood clot in the lung)
g. Required Warfarin or had injections in the tummy for any reason
If you have had previous treatments for your veins what method was used (Please circle)
By whom and when.
Did you have any problems afterwards? .
Were you happy with the overall results? .
Past Medical History
Do you have a history of: (Please circle)
b. Hepatitis - A, B, or C, please indicate
c. Blood transfusions
e. Diabetes - on Insulin, tablets, or diet controlled
f. High blood pressure
g. Seizures, convulsions or epilepsy
i. Bad circulation
k. Arthritis or other types of autoimmune disease (e.g. Lupus) .
l. Thyroid problems - please explain.
m. Heart disease .
Other medical problems .
Gynaecological History (Ladies only)
How many times have you been pregnant? (including any termination or miscarriage).
How many children do you have?.
Are you pregnant?
Please name all operations you have had with relevant years
Do you have a family history of:
a. Varicose vein problems
g. Other problems affecting the veins or circulation? .
Do you suffer from:
e. Other psychological or psychiatric disorder
a. single or married
b. regular alcohol ./day
c. social drinker
e. occupation .
If yes, for how long?. For what reason? .
Do you take Aspirin or anti-inflammatory drugs? (e.g. Voltaren, Naprosyn, etc)
Have you had any of the following allergic reactions?
d. Anaphylactic shock (severe life threatening allergic reaction)
if yes, please explain what happened .
Do you have an allergy to any of the following?
d. Medications (i.e. tablets, capsules etc)
What are your feelings towards surgery on your veins?
a. Don't mind
b. If really necessary
Are there any pending travel arrangements?
Have you had any problems with your legs with travel?
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