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Fibrovein form
What is you first name?
What is your surname?
What is your date of birth?
Address
Postcode
Email address
Mobile number
Are you currently taking any medications, including the oral contraceptive pill?
Yes
No
If you answered yes to medications, what are they?
Do you suffer from any of the following?
Uncontrolled diabetes meleatus
Toxic Hyperthyroidism
Tuberculosis
Asthma
Migraines
Neoplasms
Sepsis
Blood Dyscrasias
Acute Respiratory Disease
Acute Skin Disease
None of the above
Do you have any allergies?
Do you smoke, if so how many a day?
Do you drink alcohol, if so how many units weekly?
What is your height?
What is your weight?
Have you ever suffered with a Deep Vein Thrombosis (DVT) and when?
Do you have any family history of vein disease?
Have you ever suffered with Thrombophlebitis and when?
Are you currently immobile?
Yes
No
Are you currently pregnant or breastfeeding?
Yes
No
Have you/or currently undertaking any radio/chemotherapy?
Yes
No
Have you ever been admitted to hospital or had any surgeries?
Yes
No
If yes to the above, what and when?
Have you had any previous vein treatments in the past?
Yes
No
If yes, when?
Do you have any long haul flights booked in the next month?
Yes
No
Where are the veins that require treatment?
Do you know how you came to have these veins?
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