TIMOTHY C. PRINGLE, M.D., PA VASCULAR & ENDOVASCULAR SURGERY COSMETIC VEIN CARE

TIMOTHY C. PRINGLE, M.D., PA VASCULAR & ENDOVASCULAR SURGERY COSMETIC VEIN CARE ______________________________________________________________________...
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TIMOTHY C. PRINGLE, M.D., PA VASCULAR & ENDOVASCULAR SURGERY COSMETIC VEIN CARE ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ 3740 N. Josey Lane, Suite 201 Carrollton, Texas 75007 Office: 972-906-1055 Fax: 972-956-0815 PATIENT HISTORY QUESTIONNAIRE (Historia Cuestionario de Paciente) Date:

What Doctor sent you to our office? Primary Care Physician (Doctor Primario) Office Number for PCP (Numero de telephone del Doctor) GENERAL INFORMATION (Informacion General) Name (Nombre): Age (Edad) Sex (Sexo)

Date of Birth (Dia de Nacimiento)

Female (Mujer)

Single (solo)

Male (Hombre)

Married (Casado)

Do you require an interpreter?

Yes

(MM/DD/YYYY)

SSN#

Race:

Divorced (Divorciado)

Widowed (Viudo)

No

Primary Language (Lenguae Primero) Home Address City/ State

Zip Code

Home Phone #

Alternate or Cellular #

Employer

Employer Phone#

Email: Pharmacy Name

Pharmacy Telephone

Are you left-handed or right-handed? Does your job involve heavy lifting or prolonged standing? Would you prefer to be contacted at work or at home? May we leave message with a family member at home or on your answering machine? #1 Emergency Contact

Name

Relationship

Phone #

Relationship

Phone #

(Nombre) #1 Emergency Contact

Name (Nombre)

Print Date: 2/7/2014 Revision Date: 3/08/2013

Page 1 of 7 Revision No. 1.0

TIMOTHY C. PRINGLE, M.D., PA VASCULAR & ENDOVASCULAR SURGERY COSMETIC VEIN CARE ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ 3740 N. Josey Lane, Suite 201 Carrollton, Texas 75007 Office: 972-906-1055 Fax: 972-956-0815

(What family member who will act as your advocate and update other family members on your health status if surgery is required)? Please identify all that apply Name

Office Phone #

Cardiologist (Heart Doctor) Pulmonologist (Lung Doctor) Podiatrist Endocrinologist Other

List Medications and current dosages (Including aspirin, vitamins, herbs etc.) List de medicamentos y dosisincluyendo, aspirina, vitaminas, hierbas, etc. Are you taking aspirin or other blood thinners (Coumadin/Warfarin) MEDICATION

Print Date: 2/7/2014 Revision Date: 3/08/2013

AMOUNT

Yes

No HOW OFTEN

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TIMOTHY C. PRINGLE, M.D., PA VASCULAR & ENDOVASCULAR SURGERY COSMETIC VEIN CARE ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ 3740 N. Josey Lane, Suite 201 Carrollton, Texas 75007 Office: 972-906-1055 Fax: 972-956-0815 Past Medical History (Historia Clinica) (Please check the box and fill in the DATE, if any of the following apply to you) (List de todas enfermedades medicas y fecha approximada)

PATIENT

MANAGING PHYSICIAN

FAMILY

EXPLAIN (Who, Age)

If you have diabetes:

Insulin

Do you take: Oral Agents

Diabetes

Yes

Diet Controlled

How long have you had diabetes?

No

Yes

No

Do you test your blood sugar every day?

No

Yes If yes, how many times /day

What are your blood sugar testing results? Breakfast Dinner

Hypertension

Yes

Cancer

Yes

Stroke

Yes

Kidney Disease

Yes

Phlebitis/Deep Vein Thrombosis

Yes

Varicose Veins or leg ulcers

Yes

Miscarriage

Yes

Heart trouble

Yes

Print Date: 2/7/2014 Revision Date: 3/08/2013

No No No No No No No No

See page 6

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Page 3 of 7 Revision No. 1.0

Lunch Bedtime

TIMOTHY C. PRINGLE, M.D., PA VASCULAR & ENDOVASCULAR SURGERY COSMETIC VEIN CARE ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ 3740 N. Josey Lane, Suite 201 Carrollton, Texas 75007 Office: 972-906-1055 Fax: 972-956-0815

Arthritis

Yes

HIV, Hepatitis

Yes

Convulsion/Seizures

Yes

Lupus

Yes

Lung Disease

Yes

Crohn’s Disease or Ulcerative Colitis

Yes

Thyroid Disease

Yes

Pulmonary Embolus

Yes

Hypercholesterolemia

Yes

Erectile dysfunction

Yes

Pain in leg w/ walking

Yes

No No No No No No No No No No No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

ALLERGIES (Please list all known allergies and reactions) ALLERGEN

REACTION

HOSPITALIZATION/SURGERY HISTORY (Please list all past hospitalizations) NAME OF HOSPITAL

Print Date: 2/7/2014 Revision Date: 3/08/2013

PURPOSE OF HOSPITALIZATION

Page 4 of 7 Revision No. 1.0

DATE

TIMOTHY C. PRINGLE, M.D., PA VASCULAR & ENDOVASCULAR SURGERY COSMETIC VEIN CARE ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ 3740 N. Josey Lane, Suite 201 Carrollton, Texas 75007 Office: 972-906-1055 Fax: 972-956-0815

Social History: (Please check the box if any of the following apply to you) Alcohol Use (alcolicas) Tobacco/ smoke

Occasionally

Never

Previously, but quit sm oking on:

Current Sm oker # of Years

(Fumar) Tobacco/ Snuff

Daily

M oderate (2-3 drinks)

Never

# Packs/Day

Previously, but quit on:

Never

Currently

NUTRITIONAL PROFILE (Please check Yes or No for each item)

Poor Fair Good Appetite: (Please check one) Have you had a large weight loss within the past year

Yes

NO

Have you had a large weight gain within the past year Are you involved in weight loss program? Do you take nutritional supplements? Do you exercise regularly?

ARE YOU EXPERINCING ANY OF THE FOLLOWING GENERAL

RESPIRATORY

NEUROLOGICAL

Good Health

Coughs or Frequent Colds

Frequent Headaches

Fatigue

Shortness of Breath

Lightheaded/Dizzy

Fever

Spitting Up Blood

Paralysis

Insomnia

Asthma/Wheezing/Emphysema/TB

CheckBox4

Stress Print Date: 2/7/2014 Revision Date: 3/08/2013

GASTROINTESTINAL

PSYCHIATRIC Page 5 of 7 Revision No. 1.0

TIMOTHY C. PRINGLE, M.D., PA VASCULAR & ENDOVASCULAR SURGERY COSMETIC VEIN CARE ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ 3740 N. Josey Lane, Suite 201 Carrollton, Texas 75007 Office: 972-906-1055 Fax: 972-956-0815 EYES

Loss of Appetite

Memory

Wear Glasses/Contacts

Nausea/Vomiting

Nervouse/Depression

Glaucoma or Cataracts

Diarrhea

Claustrophobia

EARS, NOSE, MOUTH, THROAT Earaches Hearing Loss/Ringing in Ears

Constipation Blood in Stool

HEMATOLOGICAL/LYMPHATIC

ENDOCRINE Hormone Replacement Therapy Excessive Thrist or Urination

Nosebleeds

Slow Healing After Cuts

Sinus Problems

Anemia

Sore Throat or Mouth Sores

Blood Transfusions

Rash/Itching

Dental Problems

Bleeding/Bruising

Change in Skin/Hair/Nails

Swollen glands in nack

Blood Disorders

Yellow Jaundice

CARDIOVASCULAR Chest Pain Pacemaker Insertion

ALLERGY/IMMUNOLOGIC Environmental Allergies

MUSCULOSKELETAL

Heat/Cold Tolerance

INTEGUMENTARY / BREAST

GENITOURINARY Frequent Urination Painful/Burning Urination

Irregular/Fast Heartbeat

Joint Pain/Swelling

Bladder Control Problem

Numbness/Weakness Extremities

Muscle/Joint Weakness

Kidney Stones

Swelling of Feet/Ankles

Back Pain

Change in Force/Stream

Pain when Walking

Joint Stiffness

Venereal Disease

FOR WOMEN ONLY

FOR MEN ONLY

Last Menstrual Period

Testicle Pain

How many Pregnancies

Prostate Problems

Blood in Urine

Vein Questionnaire Print Date: 2/7/2014 Revision Date: 3/08/2013

Page 6 of 7 Revision No. 1.0

TIMOTHY C. PRINGLE, M.D., PA VASCULAR & ENDOVASCULAR SURGERY COSMETIC VEIN CARE ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ 3740 N. Josey Lane, Suite 201 Carrollton, Texas 75007 Office: 972-906-1055 Fax: 972-956-0815 Spider Veins Varicose Veins Bulging Veins 1. Do you have any of the following 2. Which of the following are causing you concern? (Circle all that apply)

Bulging Varicose Veins

Spider Veins

Leg Swelling

3. How long have your veins caused you problems 4. Does your legs limit your daily activities due to discomfort

No

Yes Yes

5. Does prolong sitting or standing aggravate your veins

No

6. Have you ever noticed any of the following during activity or after prolonged standing?

Aching

Fatigue

Swelling

Exercise Intolerance

Itching

Exercise Intolerance

Pain

Burning

Feeling of Heaviness

Skin Changes

7. Have you ever had any of the following? (Check all that apply)

Slow or Non-Healing Skin Ulceration

Bleeding from Veins

Darkening of the Skin

8. Have you ever been treated for ulcerations or blood clot in your legs? Done?

No

Yes

If yes, what was

9. In the past months or years, how many of the following conservative treatments have you attempted?

Compression Stockings Medications Bad Reactions to Anesthesia?

Weight Loss Program

Exercise

Leg Elevation

(Name)

Yes

No

N/A

If yes, please (Specify)

* PLEASE USE THIS SPACE TO LIST ANY OTHER MEDICAL INFORMATION YOU FEEL IS NECESSARY AND WAS NOT ADDRESSED IN THE QUESTIONNAIRE To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the doctor’s office of any changes in my medical status.

Patient’s Name (Printed)

Date

Patient’s Signature

Print Date: 2/7/2014 Revision Date: 3/08/2013

Page 7 of 7 Revision No. 1.0