PATIENT SELF-ASSESSMENT

Patient Self-Assessment
Please take this self-assessment to see if you might be a candidate for additional screening for potential varicose veins and / or chronic venous insufficiency.

History


Have you ever had varicose veins?

  Yes

  No

Signs and Symptoms
Do you experience any of the following signs and symptoms in your legs or ankles?


Do you experience leg pain, aching or cramping?

  Yes

  No

Do you experience leg or ankle swelling, especially at the end of the day?

  Yes

  No

Do you feel “heaviness” in your legs?

  Yes

  No

Do you experience restless legs?

  Yes

  No

Do you have skin discoloration or texture changes?

  Yes

  No

Do you have open wounds or sores?

  Yes

  No

Risk Factors


Has anyone in your blood-related family ever had varicose veins or been diagnosed with venous reflux disease or chronic venous insufficiency?

 

  Yes

 

  No

Have you had any treatments of procedures for vein problems?

  Yes

  No

Do you stand for long periods of time, such as at work?

  Yes

  No

Self-Assessment Results
If you answered yes to one or more of the above questions, please contact us for a consultation to see if you may be candidate for venous reflux disease.