Venous duplex ultrasound report | Phone survey | Patient chart |
Study date | Race | Sex |
Study indication | Ethnicity | Height |
Reflux location(s) | History of VLU (including ulcer start date) | Weight |
Reflux time(s) | Limitation of ankle movement | Venous dermatitis |
Presence of DVT or superficial vein thrombosis | Mobility (ie, use of a wheelchair or walker) | Lipodermatosclerosis |
History of DVT or PE | Atrophie blanche | |
History of varicose veins | Medical and surgical history | |
History of leg swelling | Ulcer photograph | |
Chronic itch of lower extremities | ||
Chronic rash of lower extremities | ||
Lower extremity vein procedures | ||
Lower extremity artery procedures | ||
Use of compression on lower extremities | ||
Elevation of legs when sleeping | ||
No of pregnancies | ||
Other medical and surgical history | ||
Medications | ||
Smoking history | ||
Exercise | ||
Family history of leg ulcers, swelling or varicose veins |
DVT, deep vein thrombosis; PE, pulmonary embolism; VLU, venous leg ulcer.