San Antonio Office
210-561-9995
Kerrville Office
830-257- 6316
Toll Free
1-877-411 VEIN
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CONFIDENTIAL MEDICAL HISTORY FORM

Patient’s Name *:
Date of Birth :
Check reason(s)for visit : Varicose Veins Spider Veins Hemorrhoids
1. When did you first notice the above problem(s)?
2. Have you seen another physician for this problem? Yes No
- if yes, who?
What treatment/testing was recommended?
- Was the treatment/testing done? Yes No
3. List any significant illnesses for which you are currently under a physician’s care:
4. Medication allergies?
Penicillin : Yes No
Local Anesthetic : Yes No
Other :
5. List current medications, both prescription and non-prescription, including birth-control pills, aspirin, herbs, etc. and dosages:
6. List previous operations including cosmetic surgery:
7. Do you drink alcohol?  Yes No    If so, how much?
Do you smoke? Yes No    If so, how much?
8. Are you pregnant or planning a pregnancy soon? Yes No
9. Do you have a pacemaker? Yes No
Review of Medical History
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): Yes No Details :
Tests Performed:
Ultrasound of Veins Yes Never Date :
Results :
Rectal Exam Yes Never Date :
Results :
Stool Occult Blood Yes Never Date :
Results :
Sigmoidoscopy Yes Never Date :
Results :
Colonoscopy Yes Never Date :
Results :
Review of Symptoms :
Legs (Varicose or Spider Veins):   Rectum (Hemorrhoids):  
Aching Yes   No Burning Yes   No
Itching Yes   No Itching Yes   No
Numbness or Tingling Yes   No Bleeding Yes   No
Fullness or Pressure Yes   No Protrusion Yes   No
Swelling Yes   No Constipatio Yes   No
Leg Restlessness Yes   No    
Muscle Cramping Yes   No    

Patient's Signature :

Date :

Varicose Veins
Spider Veins
Hemorrhoids
Patient Testimonials
  
San Antonio Office
8535 Wurzbach Road
Galaxy Plaza 2, Suite 106
San Antonio, TX 78240
Kerrville Office
723 Hill Country Drive
Suite C
Kerrville, TX 78028
Varicose Veins | Spider Veins | Hemorrhoids
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