First Visit Form 2

	Do you currently have any of the following conditions or problems (Continued from Page 1)?

Liver Problems

Misc.

Diabetes

arthritis

Alcohol Consumption

Light headedness

Dizziness

Kidney problems	Blood problems	Bleeding problems
			Pains in the legs or calfs with walking

		Weakness of an arm or leg	Temporary loss of vision in one eye
Swelling of the ankles	Cancer	Weakness of an arm or leg	Temporary loss of vision in one eye	Stroke

	Have you ever had an allergy or reaction to dye used in arteriograms, cardiac caths or CT Scans?

	Yes		No		Never had dye

	Have you ever had an allergy or reaction to shellfish?

	Yes		No

	Family History:

	Please list any history of heart disease, cancer, blood vessel disease, etc, in your family. Please also list the name of the person and relationship to you as related to the disease or condition.

	Please bring in a separate written list of medications, and over the counter medications, vitamins and supplements for review by Vascular Solutions Doctors.

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36001 Euclid Ave, Willoughby, Ohio, 44094

Web Site by Mark Goldberg, MD

Vascular and Endovascular Surgeons Treating Peripheral Vascular Disease in Cleveland, Ohio