Patient Registration Form (Beginning of form field)

Patient's name:

Gender: (Options: Male or Female)

Address:

Date of birth:

Home phone number:

Cell phone number:

E-mail address:

Name of employer:

Occupation:

Work phone number:

What is your work shift: (Options: 1st Shift, 2nd Shift, and 3rd Shift)

Marital status: (Options: Single, Married, Divorced, or Widowed)

If married, name of spouse:

Are you a former patient of the Vein Center of NE Ohio: (Options: Yes or No)

How were you referred to the Vein Center of NE Ohio: (Options: Physician, Family member or Friend or Patient, and Self-Referral)

Emergency contact name and phone number (not home number):

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Please bring your insurance cards with you.
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Insurance: If your insurance does not have an ID# printed on it, please provide the following information:

Policy holder's name:

Policy holder's Social Security number:

Policy holder's employer's name:

*Without this information, we will not be able to file your claim for you. The charges will be your financial responsibility.

Special Medical History Data for Leg Pain/Varicose Vein Evaluation

Please take a few minutes to complete this form prior to your office visit.

How did you learn about Dr. Sudheendra or the Vein Center of NE Ohio? (Options: Newspaper, Radio, Friend, Physician, Yellow Pages, Signage, and Other)

Section 1

Current problem(s) with legs (reason for this evaluation): (Options: Varicose veins, Spider veins, Leg pain, Achiness/heaviness/tingling, Edema/swelling, Leg ulcer, and/or Restlessness)

Where is the pain:

Back (Options: Right leg side or Left leg side and How many years)
Lower limbs (Options: Right leg or Left leg and How many years)
Thigh (Options: Right leg or Left leg and How many years)
Calf (Options: Right leg or Left leg and How many years)
Foot (Options: Right foot or Left foot and How many years)

Is the pain exacerbated (made worse) by:

Long periods of standing (Options: Yes or No)
Heat (Options: Yes or No)
Cold (Options: Yes or No)
Medications (Options: Yes or No)
Walking or exercise (Options: Yes or No)
Menstrual periods (Options: Yes or No)
Other (please specify):

Is the pain alleviated (lessened) by:

Walking or moving about (Options: Yes or No)
Elevation of legs (Options: Yes or No)
Lowering of legs or feet (Options: Yes or No)
Wearing elastic stockings (Options: Yes or No)

How long (if you have ever) have you worn elastic stockings?

Other (please specify):

Section 2

Do you have swelling or edema of the legs/ankles/feet? (Options: Yes or No)

If yes, which side? (Options: Right or Left)

When is it present? (Options: Morning or Evening)

Have you ever had an open sore or ulcer on your leg, ankle, or toe? (Options: Yes or No)

Have you ever had a superficial phlebitis (tender, red, thickened cord along path of a vein)? (Options: Yes or No)

Have you ever had deep vein thrombosis (blood clots in deep veins of leg)? (Options: Yes or No)

If yes, were you hospitalized? (Options: Yes or No)

Were you given anticoagulants (blood thinners)? (Options: Yes or No)

Did this happen after pregnancy, surgery, or injury? (Options: Yes or No)

Did the blood clot pass into your lung (pulmonary embolism)? (Options: Yes or No)

When did your vein problem first begin?

Has your problem worsened within the past 6 to 12 months? (Options: Yes or No)

What type of work do you do?

In a usual day, how much time is spent standing? (Options: 10% of the day, 25% of the day, 30% to 50% of the day, and More than 50%)

For women only:

Date of last menstrual period:

Is there a possibility you might be pregnant? (If yes, please inform Dr. Sudheendra.) (Options: Yes or No)

Have you had a tubal ligation (sterilization) or hysterectomy? (Options: Yes or No)

Are you taking birth control pills? (Options: Yes or No)

Has your husband had a vasectomy? (Options: Yes or No)

Is there any other information of medical importance that you feel the doctor should know about? (Options: Yes or No)

If yes, please describe:

I hereby consent Dr. Sudheendra or his staff to take photographs of my leg veins to assist in my treatment, to document my problems for my insurance company, and to use in educational settings as Dr. Sudheendra deems useful.

Electronic Signature:

Date:

(End of form field)