Let’s get started with your
Patient Self-Assessment

HAVE YOU EVER HAD VARICOSE VEINS?
YesNo

DO YOU EXPERIENCE LEG PAIN, ACHING OR CRAMPING?
YesNo

DO YOU EXPERIENCE LEG OR ANKLE SWELLING, ESPECIALLY AT THE END OF THE DAY?
YesNo

DO YOU FEEL “HEAVINESS” IN YOUR LEGS?
YesNo

DO YOU EXPERIENCE RESTLESS LEGS?
YesNo

DO YOU HAVE SKIN DISCOLORATION OR TEXTURE CHANGES?
YesNo

DO YOU HAVE OPEN WOUNDS OR SORES?
YesNo

HAS ANYONE IN YOUR BLOOD-RELATED FAMILY EVER HAD VARICOSE VEINS OR BEEN DIAGNOSED WITH VENOUS REFLUX DISEASE OR CHRONIC VENOUS INSUFFICIENCY?
YesNo

HAVE YOU HAD ANY TREATMENTS OR PROCEDURES FOR VEIN PROBLEMS?
YesNo

DO YOU STAND FOR LONG PERIODS OF TIME, SUCH AS AT WORK?
YesNo