Find a Doctor
Medical Information
Health Library
Events and Classes
Your Visit at SCH
Healing Environment
About Us
Swedish Covenant Hospital Foundation
Advertising
Nursing
Careers
My Health Space
Online Shops
RELATED TOPICS
> Should you have your varicose veins treated?
> Register for a free vein consultation
> Find a Doctor
> Galter LifeCenter
> Health Library
> Vascular Services
Comprehensive Vien Care Clinic Venous History
Thank you for choosing Swedish Covenant Hospital as your Vein Care Clinic. Please answer the following questions by pressing the Tab key or using your mouse to advance through the fields. When finished, click on the submit button.
* All all Fields are required.
  INTRODUCTION
FIRST NAME
LAST NAME
DATE OF BIRTH
EMAIL
GENDER  MALE  FEMALE
AGE
HEIGHT
WEIGHT
DO YOU HAVE VARICOSE VEINS? YES  NO
DO YOU HAVE SPIDER VEINS? YES  NO
WHICH LEG(S) IS(ARE) AFFECTED?  RIGHT    LEFT  
HAVE YOUR VEINS GOTTEN WORSE IN THE RECENT MONTHS? YES  NO
  SYMPTOMS
DO YOU EXPERIENCE ANY OF THE FOLLOWING IN YOUR LEG(S)?
     ACHING/PAIN? YES  NO
     HEAVINESS? YES  NO
     TIREDNESS/FATIGUE? YES  NO
     ITCHING/BURNING? YES  NO
     SWOLLEN ANKLES? YES  NO
     LEG CRAMPS? YES  NO
     RESTLESS LEGS? YES  NO
     THROBBING? YES  NO
     COLOR CHANGES? YES  NO
     ULCERS OR SORES? YES  NO
DO YOU ELEVATE YOUR LEGS TO RELIEVE THE DISCOMFORT? YES  NO
DO YOUR LEGS BOTHER YOU WHILE YOU ARE WALKING? YES  NO
DO YOU WEAR COMPRESSION STOCKINGS THAT WERE PRESCRIBED BY A HEALTHCARE PROFESSIONAL YES  NO
IF SO, DO THEY PROVIDE RELIEF? YES  NO
  LIFESTYLE
WHAT IS YOUR OCCUPATION?
DO YOU SPEND MORE TIME STANDING OR SITTING?  STANDING   SITTING
DO YOU SMOKE OR USE TOBACCO PRODUCTS? YES  NO
HOW OFTEN DO YOU EXERCISE PER WEEK?
  FAMILY AND MEDICAL HISTORY
PLEASE LIST ANY MEDICAL CONDITIONS (E.G. HIGH BLOOD PRESSURE, DIABETES, ECT.) THAT YOU HAVE
HAVE YOU EVER HAD A BLOOD CLOT IN YOUR VEINS, OTHERWISE KNOWN AS A DEEP VEIN THROMBOSIS? YES  NO
     IF SO, WHERE? 
HAVE YOU HAD ANY PRIOR TREATMENT FOR VARICOSE OR SPIDER VEINS? YES  NO
     IF SO, PLEASE LIST DATE(S) & TYPE(S) OF PROCEDURE?
     
DOES ANY MEMBER OF YOUR IMMEDIATE FAMILY (PARENT/BROTHER/SISTER) HAVE VARICOSE OR SPIDER VEINS? YES  NO
     IF SO, WHO? 
  PREGNANCY HISTORY(for women only)
ARE YOU CURRENTLY PREGNANT? YES  NO
HOW MANY TOTAL PREGNANCIES HAVE YOU HAD?
ARE YOU PLANNING ON BECOMING PREGNANT ANY TIME SOON? YES  NO
ARE YOU PRESENTLY BREASTFEEDING? YES  NO
  ALLERGIES & MEDICATIONS
DO YOU HAVE AN ALLERGY TO LATEX? YES  NO
PLEASE LIST ANY MEDICATION ALLERGIES YOU MAY HAVE
PLEASE LIST ANY MEDICATIONS (PRESCRIPTION/OVER-THE-COUNTER) OR SUPPLEMENTS YOU ARE CURRENTLY TAKING
* REQUIRED FIELD.
    
  |     |  


Contact Us   |   Privacy Statement   |   Site Map   |   Copyright and Legal
5145 N. California Ave, Chicago, IL 60625   |   773.878.8200   |   TTY 773.989.4855
© 2003 - 2010 Swedish Covenant Hospital