Let’s get started with your
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.

    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