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Patient History

Please complete the patient history below and press submit to send your patient history to Vascular Solutions.

Vascular Solutions - Patient History
Name: *
 Date: *
Email Address

Do you have or have you ever had any of the following?
Aneurysm *
  • Yes
  • No
 Heart Attack *
  • Yes
  • No
High Blood Pressure *
  • Yes
  • No
 Chest Pain Or Pressure *
  • Yes
  • No
Diabetes *
  • Yes
  • No
 Cancer *
  • Yes
  • No
Stroke *
  • Yes
  • No
 Presently Smoking *
  • Yes
  • No
High Cholestrol *
  • Yes
  • No
 Never Smoked *
  • Yes
  • No
Shellfish / Iodine Allergy *
  • Yes
  • No
 Former Smoker *
  • Yes
  • No
High Cholestrol *
  • Yes
  • No
 Year Quit
Packs Per Day
Past Surgeries *
 Current Medications *
Drug Allergies *
  • Yes
  • No
 If Yes, What Drugs Are You Allergic To?

Immediate Family History (Father, Mother, Brother, Sister or Child)
IMH - Cancer *
  • Yes
  • No
 IMH - Aneurysm *
  • Yes
  • No
IMH - Heart Attack *
  • Yes
  • No
 IMH - High Blood Pressure *
  • Yes
  • No
IMH - Stroke *
  • Yes
  • No
 IMH - Diabetes *
  • Yes
  • No

Do You Take The Following:
Coumadin *
  • Yes
  • No
 Metformin *
  • Yes
  • No
Aspirin *
  • Yes
  • No
 Plavix *
  • Yes
  • No