AVTIC - Advanced Vein Treatment & Imaging Center

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APPOINTMENT PREFERENCE

Priority	Date	Time
Primary:
Secondary:
Tertiary:

Please fill out the following form as completely as possible to allow us to follow up on your request. Your information will not be shared with anyone, in accordance with HIPAA guidelines.

Call us at (708) 424-VEIN for more appointment times and immediate answers to any questions you may have.

CONTACT INFORMATION

First Name:	Last Name:
Address: City: State: Zip:
Phone:	Email:

MEDICAL HISTORY

Birthdate:

Gender: Female Male

Who is your primary physician?
Is this your first consultation with Dr. Safvi? Yes No
Have you ever been hospitalized before? Yes

Please specify when and for what reason:

Have you ever had any kind of surgery? Yes

Please explain:

List any allergies you have:
List all of the medications you currently take, including dosages and frequency:

VEIN HISTORY What is the reason you are seeking treatment? Cosmetic Medical
Have you seen any other doctors for treatment of your veins? Yes

Please explain:

Have you ever worn compression stockings? Yes

Please list what types you have used:

Have they been of any help? YesNo

Have you ever had a blood clot in your legs? Yes

Please detail when and in which leg:

Do you experience any of the following symptoms in your legs?

Aching / Pain	Swollen Ankles
Heaviness	Leg Cramps
Tiredness / Fatigue	Throbbing
Itching / Burning	Restless Legs
Others:

Do you have problems walking? Yes

Please explain:

Are your symptoms worse at the end of the day? Yes No
Are the problems interfering with your lifestyle? Yes No

Call us at (708) 424-VEIN 3900 West 95th Street, Suite 7A Evergreen Park, IL 60805