Vascular Surgery Intake Form

The Vascular Surgery Intake Form is purpose-built for vascular surgery practices, capturing the detailed vascular history and functional assessment that vascular surgeons need for operative planning and longitudinal care management. This template collects patient demographics alongside a comprehensive vascular disease assessment including peripheral arterial disease (PAD) staging using the Rutherford classification, claudication distance and limiting symptoms, rest pain assessment, tissue loss documentation (wound location, size, Wagner grade for diabetic ulcers), venous insufficiency staging using the CEAP classification, varicose vein symptom scoring, history of deep vein thrombosis or pulmonary embolism, and aortic aneurysm surveillance history with most recent diameter measurements.

Designed for general vascular surgery, endovascular surgery, wound care, and vascular laboratory practices, this form includes sections for prior vascular interventions (open bypass grafting, endarterectomy, angioplasty, stenting, atherectomy, thrombolysis, IVC filter placement, vein ablation, sclerotherapy), non-invasive vascular laboratory results (ankle-brachial index, segmental pressures, duplex ultrasound, CT angiography, MR angiography), current anticoagulation and antiplatelet therapy, and cardiovascular comorbidity documentation. The cardiac risk assessment captures prior myocardial infarction, coronary revascularization, heart failure, arrhythmia, valvular disease, and functional capacity using the revised cardiac risk index (RCRI), which is critical for perioperative risk stratification in vascular surgery patients.

All fields are HIPAA-compliant and optimized for the vascular surgery workflow. The multi-page format allows patients to document their vascular disease history comprehensively before the surgical consultation, including interventions performed at outside facilities and prior imaging studies. This pre-visit data collection enables the vascular surgeon to review the arterial and venous anatomy, assess operative candidacy, and determine whether open surgical, endovascular, or hybrid approaches are most appropriate before the face-to-face evaluation.