Have you experienced any of the following?
 

YES

NO

  IF YES, PLEASE DESCRIBE
WEAKNESS / FATIGUE    

RECENT WEIGHT GAIN OR LOSS    

SYNCOPE (FAINTING) OR NEAR SYNCOPE    

CHEST PAIN OR PRESSURE    

CHEST TIGHTNESS / DISCOMFORT    

SHORTNESS OF BREATH    

ORTHOPNEA (NEED TO SLEEP WITH HEAD ELEVATED)    

PAROXYSMAL NOCTURNAL DYSPNEA (WAKE UP SHORT OF BREATH)    

PERIPHERAL EDEMA (LEG SWELLING)    

PALPITATIONS    

VERICOSE VEINS    

THROBOPHLEBITIS (INFLAMED VEINS)    

CLAUDICATION (PAIN IN LEGS ON EXERCISE)    

NAUSEA / VOMITTING    

ABDOMINAL PAIN    

HYPERVENTILATION (EXCESSIVELY RAPID BREATHING IN RESPONSE TO STRESS)    

ANXIETY    

DEPRESSION    

ADDITIONAL COMMENTS (IF ANY):

PAGE 3 OF 3
 

Please print this form and bring it with you to your appointment by clicking the Print button.