Patient Name: _______________________________________ |
Social Security #: _____________________________________ |
Date of Birth: ________________________________________ |
TO THE DOCTOR: Please complete the following report attaching copies of lab results for each condition. Please use the back of the form if additional space is needed. |
1. Does this patient suffer from any vascular impairment or disease? ____YES ____NO. If yes, |
A. What is the current diagnosis? ___________________________________________ ____________________________________________________________________ |
| B. On what date was the diagnosis first made? _________________________________ |
| C. What is the date of onset, if different? ______________________________________ |
| D. How long have you been treating the condition? ______________________________ |
| E. What is the date of the most recent examination? _____________________________ |
| F. What was the patient's height_____ weight ____ at that time? |
NOTE: If the diagnosis is DIABETIC ARTERIOSCLEROTIC DISEASE, alternate forms will be provided. Do not complete this form unless there is an independant vascular impairment. |
2. Does patient suffer from: |
|
A. Peripheral arteriosclerotic disease? ____ YES ____NO Which extremity ___________________________________________________ |
|
B. Chronic ischemia? ____ YES ____NO Which extremity ___________________________________________________ |
|
C. Temporal arteritis (polymyalgia rheumatia)? ____ YES ____NO Which extremity ___________________________________________________ |
|
D. Thromboangitis (Buerger's Disease)? ____ YES ____NO Which extremity ___________________________________________________ |
| E. Venous Thrombosis ____ YES ____NO If so, is it: |
|
1. Deep venous thrombosis? ____ YES ____NO Extremity______________________________________________ |
|
2. Chronic venous insufficiency? ____ YES ____NO Extremity______________________________________________ |
|
3. Thrombophlebitis? ____ YES ____NO Extremity______________________________________________ |
| 3. | What diagnostic procedures have been performed? | ||||
| Yes | No | Date | Results | ||
| A. | Angiography | _____ | _____ | _____ | _________ |
| B. | Arteriogram | _____ | _____ | _____ | _________ |
| C. | Doppler ultrasound | ||||
| exercise | _____ | _____ | _____ | _________ | |
| at rest | _____ | _____ | _____ | _________ | |
| D. | Venography | _____ | _____ | _____ | _________ |
| E. | Radioactive fibrinogen |
_____ | _____ | _____ | _________ |
| F. | Palpitation of superficial veins |
_____ | _____ | _____ | _________ |
| G. | Plethysmography | _____ | _____ | _____ | _________ |
| 4. What is the resting ankle/brachial systolic blood pressure ratio? _________________ |
| 5. Are there decreases in systolic blood pressure at ankle? ____YES ____NO |
| 6. What symptoms has the patient reported or have you observed symptoms consistent with the diagnosis? |
| DATE(S) | |||||
| A. | intermittent claudication? | ___YES | ___NO | _______ | |
| with pain? | ___YES | ___NO | _______ | ||
| ache? | ___YES | ___NO | _______ | ||
| cramps? | ___YES | ___NO | _______ | ||
| fatigue on exertion? | ___YES | ___NO | _______ | ||
| weakness on exertion? | ___YES | ___NO | _______ | ||
| which extremity_____________________________________________ | |||||
| duration___________________________________________________ | |||||
| B. | pain on exertion? | ___YES | ___NO | _______ | |
| location (check all appropriate and describe) | |||||
| |
-calf _________________________________ | ||||
| -foot _________________________________ | |||||
| -thigh ________________________________ | |||||
| -hip __________________________________ | |||||
| -buttocks _____________________________ | |||||
| C. | pain at rest? | ___YES | ___NO | _______ | |
| which extremity_____________________________________________ | |||||
| duration___________________________________________________ | |||||
| D. | reduced or absent pulses in extremity? | ___YES | ___NO | _______ | |
| which extremity_____________________________________________ | |||||
| duration___________________________________________________ | |||||
| E. | pallor of skin? | ___YES | ___NO | _______ | |
| which extremity_____________________________________________ | |||||
| duration___________________________________________________ | |||||
| F. | delayed venous filling time following elevation? | ___YES | ___NO | _______ | |
| which extremity_____________________________________________ | |||||
| duration___________________________________________________ | |||||
| G. | problems with feet; pain coldness, numbness? | ___YES | ___NO | _______ | |
| dry scaly skin? | ___YES | ___NO | _______ | ||
| poor nail and hair growth? | ___YES | ___NO | _______ | ||
| which foot_________________________________________________ | |||||
| duration___________________________________________________ | |||||
| H. | ulceration? | ___YES | ___NO | _______ | |
| which extremity_____________________________________________ | |||||
| I. | atrophied leg? | ___YES | ___NO | _______ | |
| which leg__________________________________________________ | |||||
| duration___________________________________________________ | |||||
| J. | necrosis or gangrene: | ___YES | ___NO | _______ | |
| which extremity_____________________________________________ | |||||
| duration___________________________________________________ | |||||
| K. | phlebitis? | ___YES | ___NO | _______ | |
| which extremity_____________________________________________ | |||||
| duration___________________________________________________ | |||||
| L. | statis pigmentation? | ___YES | ___NO | _______ | |
| location___________________________________________________ | |||||
| duration___________________________________________________ | |||||
| M. | stasis dermatitis? | ___YES | ___NO | _______ | |
| location___________________________________________________ | |||||
| duration___________________________________________________ | |||||
| N. | tenderness? | ___YES | ___NO | _______ | |
| location___________________________________________________ | |||||
| duration___________________________________________________ | |||||
| O. | pain? | ___YES | ___NO | _______ | |
| location___________________________________________________ | |||||
| duration___________________________________________________ | |||||
| P. | edema? | ___YES | ___NO | _______ | |
| location___________________________________________________ | |||||
| duration___________________________________________________ | |||||
| Q. | warmth? | ___YES | ___NO | _______ | |
| location___________________________________________________ | |||||
| duration___________________________________________________ | |||||
| R. | discoloration? | ___YES | ___NO | _______ | |
| location___________________________________________________ | |||||
| duration___________________________________________________ | |||||
| S. | prominence of superficial veins? | ___YES | ___NO | _______ | |
| location___________________________________________________ | |||||
| duration___________________________________________________ | |||||
| T. | loss of peripheral arterial pulses? | ___YES | ___NO | _______ | |
| location___________________________________________________ | |||||
| duration___________________________________________________ | |||||
| 7. Is the patients mobility impaired? | ___YES | ___NO | |||
| Of so, why?___________________________________________________ | |||||
| ______________________________________________________________ | |||||
| Impaired to what degree?___________________________________________ | |||||
| 8. Has surgery been recommended or performed? | ___YES | ___NO | |||
| If so, what procedure? | |||||
| YES | NO | Dates | |||
| A. | surgical reconstruction | ____ | ____ | _______ | |
| thromboen darterectomy | ____ | ____ | _______ | ||
| bypass graft | ____ | ____ | _______ | ||
| resection | ____ | ____ | _______ | ||
| Percutaneous translumiral angioplasty | ____ | ____ | _______ | ||
| Please describe the procedure, attach a copy of the surgical results and procedures to this report. | |
| 9. | What medications have been prescribed? (Attach a list if needed) |
| Medication ________________________________________________________ | |
| Dosage ___________________________________________________________ | |
| Date Prescribed _____________________________________________________ | |
| 10. | What is the present therapy for the condition ________________________________ |
| __________________________________________________________________ | |
| 12. | What medications is the patient currently taking for the condition__________________ |
| __________________________________________________________________ | |
| __________________________________________________________________ | |
| 13. | Are there any side effects from the medication observed or reported? YES ____ NO ___ |
| If so, what are they? __________________________________________________ | |
| __________________________________________________________________ | |
| 15. | What other medical or psychological condition does the patient suffer in addition to those described above? |
| __________________________________________________________________ | |
| __________________________________________________________________ | |
| 16. | Are you treating these other conditions? YES ____ NO ____ |
|
Date Report Completed: | ______________________________ |
| Signature of Physician: | ______________________________ |
| Physician Name: | ______________________________ |
| Address: | ______________________________ |
| Telephone: | ______________________________ |
| Specialty: | ______________________________ |