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
Page 2 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 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