Comprehensive Vascular Surgery Patient History Form

Patient Information

• Full Name: _________________ Date of Birth: _________
• Age: ____ Gender: ______ Height: ______ Weight: ______

Chief Complaint

• Primary reason for visit: _________________________
• Duration of symptoms: ___________________________

Vascular History

Current Symptoms (check all that apply):

• Leg pain/claudication
• Rest pain
• Ulcers/wounds
• Varicose veins
• Swelling
• Color changes in extremities
• Numbness/tingling

Previous Vascular Procedures

• Previous vascular surgeries: Yes [ ] No [ ]
• If yes, please list with dates:
  1. _________________ Date: _________
  2. _________________ Date: _________

Cardiovascular History

• High blood pressure: Yes [ ] No [ ]
• Heart disease: Yes [ ] No [ ]
• Previous heart attacks: Yes [ ] No [ ]
• Irregular heartbeat: Yes [ ] No [ ]

Risk Factors

• Smoking: Never [ ] Former [ ] Current [ ]
  • If current/former: ____ packs/day for ____ years
• Diabetes: Yes [ ] No [ ]
• High cholesterol: Yes [ ] No [ ]

Current Medications

Allergies

• Medication allergies: ___________________________
• Contrast dye allergy: Yes [ ] No [ ]

Family History

• Blood clots: Yes [ ] No [ ]
• Aneurysms: Yes [ ] No [ ]
• Early heart disease: Yes [ ] No [ ]

Additional Information

• Recent imaging studies: ________________________
• Other medical conditions: ______________________

Authorization

I confirm that the information provided above is accurate to the best of my knowledge.

Signature: _________________ Date: _________