Vascular Assessment Form
Surname
Forenames	Student
Occupation	URN

Presenting Complaint

Diagnosed Conditions	Yes/No	Details
Diabetes Mellitis
Hypertension
Hyperlipidaemia
CVA
Heart Disease
Syncope
History of vascular surgery
Family Health
DVT

Risk Factors
Smoking	Years:
	Daily amount:
Alcohol	Daily amount:
Lifestyle
Obesity

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Content Approved by: Head of Department
Page maintained by: Podiatry Webmaster
Last Updated: October 24th, 2001