Chronic Venous Thromboembolism Screening Form

Streamline Post-DVT Patient Assessment with Chronic Venous Thromboembolism Screening

For vascular surgery practices, hematology clinics, and cardiology centers managing patients with deep vein thrombosis (DVT) history, systematic screening for chronic venous thromboembolism is essential for preventing long-term complications and ensuring appropriate specialist intervention.

This Chronic Venous Thromboembolism Screening Form provides a structured approach to evaluating post-DVT patients presenting with persistent or recurrent leg symptoms. The template systematically captures critical clinical information including symptom severity and duration, functional impact, anticoagulation therapy history, previous imaging results, and current vascular concerns—all essential data points for determining consultation urgency and treatment planning.

Why Healthcare Providers Choose This Template

Vascular surgeons can efficiently triage patients requiring specialist evaluation for chronic thromboembolic disease, capturing detailed symptom profiles and treatment history before consultation. Primary care physicians benefit from a standardized referral pathway that ensures all relevant clinical information is documented when referring patients with suspected post-thrombotic syndrome or chronic venous insufficiency.

Anticoagulation clinics use this assessment to monitor long-term outcomes in post-DVT patients, identifying those who may benefit from extended therapy or additional vascular imaging. The form's structured approach to medication review and symptom scoring helps clinicians identify patients at risk for recurrent thrombosis or developing chronic complications.

Complete Clinical Assessment in One Form

The template covers essential screening domains: demographic and medical history, detailed leg symptom assessment (pain, swelling, skin changes, ulceration), functional limitation scoring, complete anticoagulation history with adherence assessment, previous imaging studies and results, risk factor evaluation, and vascular surgery consultation preferences.

Conditional logic ensures clinicians capture appropriate detail based on symptom severity and treatment history, while maintaining an efficient workflow for routine monitoring visits. The form adapts to capture additional information for patients with complex presentations or multiple recurrence episodes.

Integrate with Your Healthcare Workflow

This form works seamlessly within your existing EMR ecosystem. Connect submissions to your practice management system, trigger automated appointment scheduling for high-priority consultations, or route completed assessments directly to vascular surgery teams for review. Need to coordinate imaging studies before consultation? Set up workflows through Stepper (stepper.io) that automatically schedule venous duplex ultrasounds or refer for advanced imaging based on clinical findings.

For practices managing large post-DVT patient populations, the standardized data capture enables quality monitoring, outcome tracking, and identification of patients who may benefit from specialized thrombosis clinics or multidisciplinary vascular care.

Built on Paperform's HIPAA-alternative compliant infrastructure with SOC 2 Type II certification, this template helps healthcare providers deliver systematic, evidence-based care for patients at risk of chronic venous thromboembolic complications.