Sclerotherapy - Elmhurst Dermatology
Sclerotherapy - Elmhurst Dermatology
Sclerotherapy - Elmhurst Dermatology
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Does your work require<br />
a. Prolonged standing position<br />
b. Prolonged sitting position<br />
12. In the course of a normal day, how much time is spent in a standing position<br />
a. 10% of the day<br />
b. 20% of the day<br />
c. 30-50% of the day<br />
d. More than 50%<br />
No Yes<br />
13. Does walking or exercise relieve or aggravate the pain<br />
14. Do you jog, run, jump rope, or do aerobics<br />
How often per week:<br />
15. Are you pregnant or planning a pregnancy soon<br />
16. Do you smoke cigarettes<br />
If yes, how many packs per day<br />
17. Do you wear elastic support stockings<br />
What kind<br />
How often<br />
18. Are you taking any medications<br />
Indicate which of the following you are taking:<br />
a. Aspirin<br />
b. Anticoagulants<br />
c. Hormones or contraceptives (birth control)<br />
d. Chemotherapy for any type of tumor<br />
e. Thyroid medication<br />
f. Cortisone<br />
g. Insulin<br />
h. Sedatives (sleeping pills)<br />
i. Tranquilizers<br />
j. Appetite suppressants<br />
k. Others (specify):
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