Comprehensive Vascular Care

8485 Bird Road STE 305B Miami, FL 33155

2100 Nebraska Avenue STE 211 Fort Pierce FL 34950
305-432-4218 (SM) 772-241-7834 (FP) 1-888-714-0425 (F)

WELCOME TO OUR PRACTICE

We strive to provide the highest quality of care to our practice in a professional and personalized manner. In order to maximize
your visit to our office we will need to gather some important information.

Please see the following new patient documents included in this packet that needs to be filled out completely before your visit to
our office. Please bring to your appointment all medical records including labs, testing and procedure results, with all your current
medications.
❖ Welcome Letter ❖ Consents
❖ Information Letter ❖ Portal Information
❖ Demographics ❖ Covid Screening
❖ Financial Policy ❖ ABN financial form
❖ Medical records authorization ❖ Medical History

Make sure you allow yourself enough time to locate our office and fill out all necessary documents, if not completed already. We
strongly recommend arriving 15 minutes prior to your appointment.

Miami Location:

Port Lucie Location:

 Comprehensive Vascular Care
8485 Bird Road STE 305B Miami, FL 33155
2100 Nebraska Avenue STE 211 Fort Pierce FL 34950
305-432-4218 (SM) 772-241-7834 (FP) 1-888-714-0425 (F)

**PLEASE KEEP THIS SHEET FOR FUTURE REFERENCE**

WELCOME TO COMPREHENSIVE VASCULAR CARE (CVC)

Dr. Bernard Ashby MD, MPP, RPVI, FACC

Dr. Ashby and staff are pleased that you have chosen CVC to provide your healthcare needs. We are committed to providing the
highest quality service to our patients. The following information is intended to assist you in successfully managing your health
care needs.

APPOINTMENT TIPS:
Please call our office at the number listed above so that we can schedule a visit appropriate to your needs. It is necessary that we
know about ALL of the medicines you are currently taking, so please all medical records that pertain to visit and all medications
to each and every appointment. It is also helpful if you write down any questions or concerns you may have so you don’t forget.
Our office will confirm your appointment the day before by phone. If you need to reschedule or cancel appointment, please make
our office aware either by phone, portal, or text to 305-432-4218.

LATE ARRIVALS AND CANCELLATIONS:

Please give us a call if you will be arriving late for your appointment so we can make the proper arrangements. In some cases, you
may have to be rescheduled if that works best. If you are unable to keep an appointment, please be considerate and cancel ahead
of time or you will be charged a No Show fee of $25 at the next visit.

TELEPHONE CALLS:
Our staff makes every effort to answer all phone calls because your health is our priority. We will return any and all calls within
the same day no later than 24 hours. If you call during clinic hours, please give our staff enough time to return your call, which
in most cases will be within 24 hours. If you are experiencing an EMERGENCY, please call 911. Please note that if you call more
than 1 time throughout the day, that will delay the staff on getting back to you on a timely manner.

INSURANCE:
CVC participates with most insurance products available in this area, but there are several different plans under each insurance
company’s umbrella of products that may have restrictions. Although our staff will work with you, it is ultimately your
responsibility to confirm with your insurance company what services provided by CVC are covered under your plan. If you have an
HMO, it is patient responsibility to make sure the referral is sent to us prior to your pending appointment date, or it may cause
to have your appointment reschedule to another day and time. Additionally, should we have to refer you to another physician or
diagnostic facility, we will make every attempt to choose one that accepts your insurance plan, but it is your ultimate
responsibility to confirm whether your plan covers the services provided by the practice or facility.

TEST RESULTS:
After you have labs done or a diagnostic test completed, the results will be reviewed by the doctor. If the results require urgent
attention, you will be notified immediately. Otherwise, all results will be reviewed at the next scheduled visit.
 Comprehensive Vascular Care
8485 Bird Road STE 305B Miami, FL 33155
2100 Nebraska Avenue STE 211 Fort Pierce FL 34950
305-432-4218 (SM) 772-241-7834 (FP) 1-888-714-0425 (F)

PRESCRIPTION REFILLS:
Routine prescriptions will be refilled through your pharmacy. Call your prescription number to your pharmacist who will then call
our office or send a request for refill. Please allow 2-3 business days for us to refill prescriptions. We strongly advise not to wait
until you run out of medication and refills to make a request, since theirs a 2-3 days

Medical records/ forms/ Letter:

To cover the time staff and physician requires to complete request, the patient will acquire a administration fee. Medical records
fees are as follow: $20 for the first 25 pages and $.50 per page after. Plus, postage if mailed. $20 fee if patient brings his or her
own USB for download. Disability forms/ reports fees are as follow: $10 fee to complete form/report. All requests must be in
writing with a color copy of ID. Please allow 3 business days to process request. Allow 48 hours for any letters that need to be
made on your behalf.

***For the safety of our staff and patients due to Covid -19, CVC’s doors are always locked. If you do
not have an appointment, please call before arriving to our office to speak to our staff. ***

GENERAL GUIDELINES FOR HEALTH MAINTENANCE

We uniformly advise a “no tobacco” policy for all patients. At your request, we will gladly provide assistance with
tobacco cessation.

Regular exercise has tremendous health benefits – especially aerobic activity (including brisk walking, you tube
workouts, classes etc.) for 30 minutes at least 5 times/week is strongly advised, unless contraindicated. At a minimum,
you should cover a distance of 1 mile/day and use stairs instead of an elevator whenever possible.

A heart healthy diet with low-sugar and low carbohydrates is suggested for all patients. Excess processed foods, trans-
fats, and sugar/carbohydrates contribute to many health problems.

We strongly recommend seat belt use as it has been shown to reduce the risk of serious injury.

We strongly recommend addressing any stressors and seeking counseling and/or treatment if needed. Your mental health
is a critical aspect of your overall health. CVC has several resources available to support our patients if requested.
 Comprehensive Vascular Care
8485 Bird Road STE 305B Miami, FL 33155
2100 Nebraska Avenue STE 211 Fort Pierce FL 34950
305-432-4218 (SM) 772-241-7834 (FP) 1-888-714-0425 (F)

Demographics
Welcome to Comprehensive Vascular Care. We are honored by your choice and committed to providing you with
the highest quality care.

Name: __________________________________________ Date of Birth: _____/_____/_____

Gender: Female Male Primary Telephone #: _______________________

Mailing Address: ____________________________________ City: _______________ State: _______

Zip Code: _____________ E-mail: _________________________________________________________

Emergency Contact name/ Relationship: _________________________________ Phone #: _________________

Primary Care Physician: ______________________ Primary Care Phone#: _________________________

Referral Physician: _________________________ Referral Physician Phone#: _____________________

Pharmacy: _______________________________ (name) ____________________________ (phone)

__________________________________________________________________________ (pharmacy address)

INSURANCE INFORMATION
Insurance carrier: ____________________________ Insurance ID #: _______________________________

Group #: _______________________ Secondary insurance name & ID: __________________________________

Patient relationship to insured: ___self ___ spouse ___child ___other

Name of insured party: ________________________________________________________________

Employer of insured party: _____________________________________________________________

*Please be prepared to present insurance card and ID at time of visit. All copay’s, co-insurance, and deductible will be collected
at time of visit. Be advise that some diagnostic testing will be an extra charge and will be collected at time of service.
 Comprehensive Vascular Care
8485 Bird Road STE 305B Miami, FL 33155
2
2 2100 Nebraska Avenue STE 211 Fort Pierce FL 34950
305-432-4218 (SM) 772-241-7834 (FP) 1-888-714-0425 (F)

FINANCIAL POLICY
• Insurance verification and authorization does not guarantee payment from insurance company. Therefore, it is the patients’
ultimate responsibility to know and understand their health benefits. Please be aware that some, or all, services might be
noncovered or considered not medically necessary by your insurance plan, and you will be held responsible for the full
treatment cost.

• All office visits copays, deductible, coinsurance and balance are payable at the time services are rendered. Cash, or credit
card is accepted form of payment. At your requested, a copy of service receipts provided will be given to you or published to
your patient portal.

• The patients assume total responsibility for the payment if the claim gets denied by their insurance company. Verification of
benefits are only an estimation, and all payments are subject to policy guidelines, medical necessity, and member eligibility,
per your specific insurance plan, at the time services are performed.

• Patient authorize Medicare benefits to be made on his or her, behalf to Dr. Bernard Ashby for any services furnished to them
by the Doctor. Patient authorize all medical information about his or her to be release to the Health Care Administration and
its agent any information needed to determine benefits payable to related services.
.
• Patient understand his or her signature, request that payment be made and authorizes release of medical information
necessary to pay claim. In Medicare assigned cases, the physician agrees to accept the charge determination of the Medicare
carrier as the full charge, and the patient is responsible for only the deductible, co-insurance, and non-covered service(s). Co-
insurance and the deductible are based upon the charge determination to the Medicare carrier.

• Statements and Collections: statements are mailed out monthly and / or published to patient portal. Balance not payed prior
to next office visit, will be collected at time of service. Payment arrangement can be made by contacting our office at 305-
432-4218. Please be aware that any failure to pay for your treatment and care will result in collection action being taken to
collect the debt owe. (IE: sent to collection agency)

• Proof of Insurance: We must obtain a copy a valid picture identification and current insurance to provide proof. If you fail to
provide the required documentation in a timely manner, you may be responsible for the total balance of claim. We are in
network with most insurance, however, it is the patient’s responsibility to know his or her benefits and relations with CVC.

• HMO/Referrals: It is the patient’s responsibility to obtain a referral from your primary care physician if your insurance plan
requires it. If you are required to have a referral and arrive to your visit without it, you will be rescheduled.

• Assignment & Release: By signing below, Patient assign his or assignment of financial benefits directly to Comprehensive
Vascular Care for services performed as allowable under standard third-party contract. Patient understands they are
financially responsible for all charges paid or not paid by insurance. Patient authorized signature on all his or her insurance
submissions and release of any information to secure payment of benefits.
CVC thanks you for choosing us as your healthcare provider. If you have any questions concerning our financial policy or fees,
or difficulty with making payment, please request to speak to office staff or Dr. Ashby.
By signing this you acknowledge that you have reviewed, read, and understand the above statements.
___________________________________ _______________________________
Signature Date
 Comprehensive Vascular Care
8485 Bird Road STE 305B Miami, FL 33155
2100 Nebraska Avenue STE 211 Fort Pierce FL 34950
305-432-4218 (SM) 772-241-7834 (FP) 1-888-714-0425 (F)

Authorization for Use / Disclosure of Health Information

Name: ___________________________________________________ DOB: ____________________________

Mailing Address: __________________________________________ Phone #: _________________________

I authorize the release of my health information for the following specific purpose:

All Healthcare information that provider has in his or her possession, including information relating to any medical
history, mental or physical condition and any treatment received by me.

Release my protected health information to the following offices:

Comprehensive Vascular Care
8485 Bird Road STE 305B Miami, FL 33155 OR 2100 Nebraska Avenue STE 211 Fort Pierce FL 34950

THE REASONS OR PURPOSE FOR THIS RELEASE OF INFORMATION ARE AS FOLLOWS:

To provide medical treatment and related services and products, and to evaluate and improve patient safety and quality of
medical care.

I UNDERSTAND THIS AUTHORIZATION WILL REMAIN IN EFFECT UNTIL MY DEATH UNLESS WRITTEN NOTICE IS
GIVEN TO WITHDRAW AUTHORIZATION.

I UNDERSTAND THAT I HAVE THE RIGHT TO REVOKE THIS AUTHORIZATION, IN WRITING, AT ANY TIME BY
SENDING A WRITTEN NOTIFICATION TO THE FOLLOWING PRACTICE. CVC Office of compliance
8485 Bird Road STE 305B Miami, FL 33155 or 2100 Nebraska Avenue STE 211 Fort Pierce FL 34950 1-888-714-0425 (F)

In addition, patient understands that health care provider cannot guarantee that the recipient will not redisclose health information
to a third party. The third party may not be required to abide by this authorization or applicable federal and state law governing
the use and disclosure of his or her health information.
Patient understand that signing this form is voluntary and that if he or she does not sign, it will not affect the commencement,
continuation or quality of treatment at CVC.

By signing this form, I authorize you to use and disclosed the protected health information described above.

________________________________________ ____________________________ ___________________

Signature of patient or Personal Representative Witness/Title Date

___________________________________________ ________________________________________________
Signature of patient or guardian Date
 COMPREHENSIVE VASCULAR CARE
8485 Bird Road STE 305B Miami, FL 33155
2100 Nebraska Avenue STE 211 Fort Pierce FL 34950
305-432-4218 (SM) 772-241-7834 (FP) 1-888-714-0425 (F)

Consents

Patient Name ___________________________________________ DOB: ___________________________

**please initial**

PATIENT CHOICE STATEMENT:

________I understand that it is my right to elect the primary care, behavior analysis, physical therapist, speech
therapist, occupational therapist, community mental health, home health service, specialist care, diagnostic
imagine facility, and any other provider / facility of my choice. My choice is free of any undue pressure or
solicitation by any employee of Comprehensive Vascular Care and further declare that my receipt of health
care services from Comprehensive Vascular Care is by choice. I have been advised by the administration
department that if for any reason I wish to change services to another health care services company it is my
right to do so.

Picture Consent:
______I grant permission to Comprehensive Vascular Care to take a photograph of me for the purpose of
attaching to my medical chart only. I understand that it will only be used for in clinic identification and will
not be shared or published outside of CVC. I hereby waive any right to inspect or approve the finished
photographs or electronic matter that may be used in conjunction with them now or in the future, and I
waive any right to royalties or other compensation arising from or related to the use of the image.

External Prescription History Consent:

I authorize the Comprehensive Vascular Care to view my external prescription history via RxHub Service. I
understand that prescription history from multiple unaffiliated medical providers, insurance companies and
pharmacy benefit manager may be viewable by providers and staff, and it may include prescription
information from several years ago.
My signature below certifies that I have understand the above paragraph and that I authorize the access.

_____________________________________ __________________ _________________

Signature DOB Date
 COMPREHENSIVE VASCULAR CARE
8485 Bird Road STE 305B Miami, FL 33155
2100 Nebraska Avenue STE 211 Fort Pierce FL 34950
305-432-4218 (SM) 772-241-7834 (FP) 1-888-714-0425 (F)

Patient Name ___________________________________________ DOB: ___________________________

**please initial**

Medical records/forms/Letter:
_______To cover the time staff and physician requires to complete request, the patient will acquire a administration
fee. Medical records fees are as follow: $20 for the first 25 pages and $.50 per page after. Plus, postage if mailed. $20
fee if patient brings his or her own USB for download. Disability forms/ reports fees/ Letters are as follow: $10 fee to
complete form/report/Letters. All requests must be in writing with a color copy of ID. Please allow 3 business days to
process request. Allow 48 hours for any letters that need to be made on your behalf.

HIPAA NOTICE OF PRIVACY: This notice is effective as of ____________________ (date).

_______I have read the Privacy notice and understand my rights contained in this notice.
By way of signature, I provide CVC with my authorization and consent to use and disclose my protected
health care information for the purpose of treatment, payment, and health care operations as described in
the Privacy Notice. __________________________________(signature) ____________________ (date)

Email:
_______I understand that by using my personal or work email to obtain any medical information from CVC
and staff, can result of many transmitting risks. CVC and Staff will use reasonable means to protect the
security and confidentiality of email correspondence. However, because of risk, CVC and staff cannot
guarantee the security and confidentiality. I consent to the use of email, accept and take full responsibility
for any risk and misconduct that may transpire. Patient agrees to not hold CVC, staff, and its trustees
responsible from any breach that may possibly arise. Patient acknowledges that he or she has the option to
use patient portal, who meets HIPAA compliance, to communicate with office and has chosen to
communicate via email instead.

Intern observation Consent:

______ I understand that myself, my family, or my child will be observed by student intern at my / our office
visit or telemedicine. The observation will be for the purpose of education and training. Students are bound by
ethical guidelines of their profession and adhere to the guidelines specified by CVC. I am aware that I can
refuse to allow students to observe at any time, and that this consent is voluntary. The consent remains valid
until I give written withdraw of consent.
 COMPREHENSIVE VASCULAR CARE
8485 Bird Road STE 305B Miami, FL 33155
2100 Nebraska Avenue STE 211 Fort Pierce FL 34950
305-432-4218 (SM) 772-241-7834 (FP) 1-888-714-0425 (F)

Patient Name ___________________________________________ DOB: ___________________________

**please initial**

Telemedicine consent:
________I understand that telemedicine is the use of electronic technology for communication for the
purpose of providing healthcare services wherever the doctor and the patient are located.
I understand that the laws that protect privacy and confidentiality, as well as the confidentiality of medical
information through the Health Insurance Portability and Accountability Act (HIPPA) also apply to
telemedicine. I authorize the Institution to provide me their diagnosis, observations, recommendations
regarding my condition through telemedicine.
________I understand that I will be responsible for any payments or coinsurances that apply to my
telemedicine visit. I consent to have my credit card be charged over the phone to settle any balances I
acquired for my telemedicine visit.
________I understand that I have the right to withhold or withdraw my consent to the use of telemedicine
during my care at any time, without affecting my right to future care or treatment.
________I have read and understood the information provided above, my rights, and obligations regarding
telemedicine. I have had the opportunity to ask questions and all of which were answered to my satisfaction.
Therefore, I hereby give my consent to the use of telemedicine for medical care.

_______I Consent to receive Text message for appointment related messages.

_______I Consent to discuss results via telephone.
_______I Consent CVC Staff to leave a voice message concerning results. __________________(phone #)
_______I give permission for my Protected Health Information to be disclosed for purposes of communicating
results, findings, and care to the designated members as listed below:

NAME RELATION PHONE NUMBER

 COMPREHENSIVE VASCULAR CARE
8485 Bird Road STE 305B Miami, FL 33155
2100 Nebraska Avenue STE 211 Fort Pierce FL 34950
305-432-4218 (SM) 772-241-7834 (FP) 1-888-714-0425 (F)

INTRODUCTION TO OUR PATIENT PORTAL

Comprehensive Vascular Care offers secure viewing and communication as a service to patients who wish to view parts
of their records and communicate with our staff and physicians.

How the Secure Patient Portal Works:

A secure web portal is a kind of webpage that uses encryption to keep unauthorized persons from reading
communications, information, or attachments. Secure messages and information can only be read by someone who
knows the right password or passphrase to log in to the portal site. Because the connection channel between your
computer and the Web site uses secure sockets layer technology you can read or view
information on your computer, but it is still encrypted in transmission between the Web site and your computer.

Protecting Your Private Health Information and Risks:

This method of communication and viewing prevents unauthorized parties from being able to access or read messages
while they are in transmission. No transmission system is perfect and we will do our best to maintain electronic
security. However, keeping messages secure depends on two additional factors: the secure message must reach the
correct email address, and only the correct individual (or someone authorized by that individual) must be able to get
access to it.
Only you can make sure these two factors are present. We need you to make sure we have your correct email address
and are informed if it ever changes. You also need to keep track of who has access to your email account so that only
you, or someone you authorize, can see the messages you receive from us.
If you pick up secure messages from a web site, you need to keep unauthorized individuals from learning your
password. If you think someone has learned your password, you should promptly go to the web site and change it.

Patient Acknowledgement and Agreement

I acknowledge that I have read and fully understand this consent form and the Policies and Procedures Regarding the
Patient Portal that appears at log in. I understand the risks associated with online communications between my
physician and me, and consent to the conditions outlined herein. In addition, I agree to follow the instructions set forth
herein and including the policies and procedures as set forth in the log in screen, as well as any other instructions that
my physician may impose to communicate with patients via online communications. All of my questions have been
answered and I understand and concur with the information provided in the answers.

_____________________________________________ ________________________
Signature Date

Email Address: ____________________________________________________________________________________________________

 COMPREHENSIVE VASCULAR CARE
8485 Bird Road STE 305B Miami, FL 33155
2100 Nebraska Avenue STE 211 Fort Pierce FL 34950
305-432-4218 (SM) 772-241-7834 (FP) 1-888-714-0425 (F)

2100 PATIENT PRE-SCREENING QUESTIONNAIRE

Due to the ongoing Covid-19 pandemic, all caregivers and patients are required to complete this form prior to be seen
at all CVC locations. Your visit is subject to approval upon completion of this form. Effective immediately, the patient is
the only one allowed to be in office, unless you are a caregiver or nurse for the patient. These rules are being enforced
to keep our patients and staff as well as the rest of your loved ones safe and healthy.
1. Has the patient, caregiver or anyone in your household travelled outside the US in the past 2 weeks (14 days).
YES NO
If YES, Where: __________________________________________________________________
2. Has the patient, caregiver or anyone in your household travelled outside of Florida in the past 2 weeks (14 days)
YES NO
If YES, Where: __________________________________________________________________
3. In the past 2 weeks (14 days) has the patient, caregiver, or anyone in your household had contact with any person
suspected to have contracted COVID-19? This includes being tested for COVID-19 and being in self quarantine for
COVID-19. YES NO
4. In the past 2 weeks (14 days) has the patient, caregiver or anyone in your household had contact with any person
confirmed to have contracted COVID-19? YES NO
5. Has the patient or caregiver currently been exposed to someone with flu-like symptoms such as cough, shortness of
breath or fever? YES NO
6. Please circle if the following symptom are currently being experienced by caregiver, patient or both within the last
72 hours:
Fever Coughing Sore Throat Muscle Aches
Stomach Pains Vomiting Diarrhea Rash
Pink Eye Red Eyes Fatigue or Feeling unwell
Difficulty breathing, shortness of breath or wheezing.
By signing below, you certified that the answers above are true.

____________________________________________ ________________________
Patient signature Date

TEMP: _______________
 A. Notifier: Comprehensive Vascular Care
B. Patient Name: C. Identification Number:

Advance Beneficiary Notice of Non-coverage (ABN)

NOTE: If _________________ doesn’t pay for “D” Below, you may have to pay.
_________________ does not pay for everything, even some care that you or your health care
provider have good reason to think you need.
D. E. Reason Medicare May Not Pay: F. Estimated
Cost
Professional office Visit, Telemedicine Due to not medical necessity per your Insurance
Labs, Ekg insurance guidelines allowable per
Ultrasounds CMS.gov

WHAT YOU NEED TO DO NOW:

• Read this notice, so you can make an informed decision about your care.
• Choose an option below about whether to receive the services listed above “D”.
Note: If you choose Option 1 or 2, we may help you to use any other insurance
that you might have, but Medicare cannot require us to do this.

G. OPTIONS: Check only one box. We cannot choose a box for you.

□ OPTION 1. I want the services listed above. You may ask to be paid now, but I
also want my insurance billed for an official decision on payment. I understand that if my
insurance does not pay, I am responsible for payment, but I can appeal to my insurance. If
insurance does pay, you will refund any payments I made to you, less co-pays or deductibles.
□ OPTION 2. I want the services listed above, but do not bill my insurance. You may
ask to be paid now as I am responsible for payment. I cannot appeal if my insurance is not
billed.
□ OPTION 3. I don’t want the services listed above. I understand with this choice I am not
responsible for payment, and I cannot appeal to see if my insurance would pay.

This notice gives our opinion, not an official Medicare decision. If you have other questions on
this notice or Medicare billing, call 1-800-MEDICARE (1-800-633-4227/TTY: 1-877-486-2048).
Signing below means that you have received and understand this notice. You also receive a copy.
I. Signature: J. Date:

CMS does not discriminate in its programs and activities. To request this publication in an
alternative format, please call: 1-800-MEDICARE or email: AltFormatRequest@cms.hhs.gov.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.
The valid OMB control number for this information collection is 0938-0566. The time required to complete this information collection is estimated to average 7
minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information
collection. If you have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard,
Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.

Form CMS-R-131 (Exp. 06/30/2023) Form Approved OMB No. 0938-0566

 COMPREHENSIVE VASCULAR CARE
8485 Bird Road STE 305B Miami, FL 33155
2100 Nebraska Avenue STE 211 Fort Pierce FL 34950
305-432-4218 (SM) 772-241-7834 (FP) 1-888-714-0425 (F)

2100
Venous/PAD Screening

Patient Name: _________________________ DOB: _____________________

What is Venous Insufficiency: Venous insufficiency is a condition that develops when the valves that usually keep blood
flowing out of your legs become damaged or diseased. This causes blood to pool in your legs.

What is PAD (Peripheral Arterial Disease): PAD is a circulatory disease that causes narrowed arteries to reduce blood
flow to your limbs (Usually legs or arms).

Do you experience any of the following in your legs/ feet?

Yes/ No Right/ Left or Both

Aching/Pain or cramps in your
thighs,
hips or calf muscles after
walking/climbing
stairs.
Numbness/ weakness

Coldness/ hair loss in legs or feet

Discoloration, Shiny or pale Skin

Bulging Varicose Veins

Spider Veins

Tiredness/fatigue

Swelling/ Edema or heaviness

Restless legs/ Throbbing

Itching/ Burning

Non-healing wounds / ulcers

 Comprehensive Vascular Care
8485 Bird Road STE 305B Miami, FL 33155
2100 Nebraska Avenue STE 211 Fort Pierce FL 34950
305-432-4218 (SM) 772-241-7834 (FP) 1-888-714-0425 (F)

Name: ________________________________DOB: _________________ Date: ____________________

Reason for visit: _______________________________________________________________________
Pharmacy Name: __________________________ Pharmacy number: ___________________________

Recent Symptoms Social History

1. Chest pains 1. Do you currently smoke
2. Shortness of breath *Number of packs per day _____________
*with exertion 2. Do you exercise routinely
*if yes, lying flat in bed *Type: _______________________________
*if yes, does it wake you at night 3. Do you currently drink caffeine
3. Swelling in your legs *Number of drinks per day: ________________
4. Do you routinely develop pain in your 4. Do you drink alcohol
legs when You walk *Number of drinks per day: ________________
5. Have you passed out recently
6. Have you felt your heart beating fast Have you ever been pregnant?
Or skipping for no reason Any complications?
If Yes, please explain the complication:
Past Medical History _________________________________________
1. High Blood Pressure _________________________________________
2. High Cholesterol _________________________________________
3. Diabetes Medication List and Dosage
4. Heart attack 1._______________________________________
5. Heart failure 2._______________________________________
6. Other: ________________________________ 3._______________________________________
________________________________________ 4._______________________________________
Allergies: ________________________________
________________________________________
OFFICE USE ONLY:
Family History
Any Heart disease in your family BP: ____________ HR: ______________
*Who and age: __________________________
RR: ___________ O2:_______________
Surgical History
1._______________________________________ HEIGHT: ________ WEIGHT: __________
2._______________________________________
3._______________________________________ BMI: ___________ TEMP: ____________
4._______________________________________