Varicose veins stopped me from doing the things I love. After all, varicose veins can be very painful. Not to mention how unsightly they are. But thanks to Vein Associates, my varicose veins are just a memory. Betty H.
952-224-8107 Call Today
952-224-8107 Call Today

Patient Registration Form

Please note that it is important to fill in all the fields before submitting. Thank you.

Last Name* :


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First Name* :
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How did you hear about us?
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Name of Primary Care Physician::
Check reason(s) for visit:
Varicose Veins
Spider Veins
When did you first notice the above problem(s)?
Have you seen another physician for this problem? Yes   No
If yes, who? When?
What treatment/testing was recommended:
Was treatment/testing done: Yes   No
List any significant illnesses for which you are currently under a physician's care:

Medication allergies:



Yes   No
Local Anesthetic: Yes   No
List current medications, both prescription and non-prescription, including birth-control pills, aspirin, herbs, etc. and dosages:
List previous operations including cosmetic surgery:
Do you drink alcohol? Yes   No If so, how much? :
Do you smoke? Yes   No If so, how much? :
Are you pregnant or planning a pregnancy soon? Yes   No    
Do you have a pacemaker? Yes   No    
Have you ever been diagnosed with any of the following?
HIV Yes   No Details :
Hepatitis or other Liver Disease Yes   No Details :
Bleeding disorder Yes   No Details :
Benign or malignant tumor Yes   No Details :
Diabetes Yes   No Details :
High Blood Pressure Yes   No Details :
Heart Disease or Stroke Yes   No Details :
Kidney disease Yes   No Details :
Asthma Yes   No Details :
Inflammation of a vein (phlebitis) Yes   No Details :
Blood clot in the legs Yes   No Details :
Blood clot in the lungs Yes   No Details :
Stomach or Intestinal Ulcers Yes   No Details :
Crohn’s Disease Yes   No Details :
Rectal Bleeding Yes   No Details :
Black Tarry Stools Yes   No Details :
Constipation or Diarrhea Yes   No Details :
Change in Bowel Habits Yes   No Details :
Family History of Colon Cancer Yes   No Details :
Neurological Disease or Epilepsy Yes   No Details :
Depression or Emotional Problems Yes   No Details :
Other (please specify):  
Prior Tests Performed:      
Ultrasound of Veins Yes   No Date :
Results :
Rectal Exam Yes   No Date :
Results :
Stool Occult Blood Yes   No Date :
Results :
Sigmoidoscopy Yes   No Date :
Results :
Colonoscopy Yes   No Date :
Results :
Review of Symptoms:
Legs (Varicose or Spider Veins)      
Aching Yes   No    
Itching Yes   No    
Numbness or Tingling Yes   No    
Fullness or Pressure Yes   No    
Swelling Yes   No    
Leg Restlessness Yes   No    
Muscle Cramping Yes   No    

Your insurance company may require documentation of certain criteria before vein therapy is considered to be medically necessary, and therefore reimbursable through them.
Do your activities, both work and home, require prolonged periods of standing? Yes   No

If yes, what activity requires prolonged periods of standing?

If yes, how many times during the day do you have to sit or take a break due to aching, cramping, burning, itching or swelling in the lower extremities?

No Once per day
2-3 times per day 4 or more times per day
Do you take over-the-counter medications (e.g., aspirin, ibuprofen, NSAIDS or a similar type of medication) or prescription medications for aching, cramping, burning or swelling of the lower extremities? Yes   No
If yes, what is the medication and dosage?

If yes, how any days in a two week period of time do you take the medication?

0-2 days 3-4 days
5-6 days   7 or more days
Have you worn prescription graded compression stockings? Yes   No

If yes, How long?  Please provide dates.


If yes, did the stockings result in a significant improvement of symptoms?

Yes   No
Strength of Stockings (in mmHg)

Please describe as completely as possible any physician’s names, clinic names and dates of treatments, as well as any prior vain therapy that you have undergone.

What conservative therapies have been utilized in an attempt to decrease your leg symptoms, and for how long (give specific dates or timeframes)?

Conservative Therapies



Leg Elevation From   /
to  /
Aspirin or Other Pain Relievers From   /
to  /
Compression Stockings From   /
to  /
Weight Loss From   /
to  /
Exercise From   /
to  /
Massage From   /
to  /
Other Therapies From   /
to  /
Specifically how do your leg symptoms affect the quality of your daily activities at work and/or home?

Activity Yes   Or   No List Specific Examples
Walking Yes   No
Driving Yes   No
Kneeling Yes   No
Exercising Yes   No
Sitting Yes   No
Standing Yes   No
Leisure Activities Yes   No
Other Yes   No

Have you ever been diagnosed with blood clots, sometimes referred to as phlebitis?

Yes   No

Have you ever experienced bleeding from the veins that was difficult to stop?

Yes   No

Have you ever had a sore on your legs that took longer to heal than you would normally expect?

Yes   No
*I, the undersigned, grant permission to Vein Associates of Edina to disclose medical information to other treating physicians regarding my care. I authorize the release to the Health Care Financing Administration or said insurance company and its agents any medical information about me to determine benefits payable for related services. I understand that I, the undersigned, am legally responsible for all fees related to medical services rendered.
*I request that payment of authorized Medicare or health insurance benefits are to be made to Vein Associates for services furnished to me.
Patient: Signature* :
Date :
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