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.

Your Medical History

HAVE YOU EVER HAD VARICOSE VEINS?
DO YOU EXPERIENCE LEG PAIN, ACHING OR CRAMPING?
DO YOU EXPERIENCE LEG OR ANKLE SWELLING, ESPECIALLY AT THE END OF THE DAY?
DO YOU FEEL “HEAVINESS” IN YOUR LEGS?
DO YOU EXPERIENCE RESTLESS LEGS?
DO YOU HAVE SKIN DISCOLORATION OR TEXTURE CHANGES?
DO YOU HAVE OPEN WOUNDS OR SORES?
HAS ANYONE IN YOUR BLOOD-RELATED FAMILY EVER HAD VARICOSE VEINS OR BEEN DIAGNOSED WITH VENOUS REFLUX DISEASE OR CHRONIC VENOUS INSUFFICIENCY?
HAVE YOU HAD ANY TREATMENTS OF PROCEDURES FOR VEIN PROBLEMS?
DO YOU STAND FOR LONG PERIODS OF TIME, SUCH AS AT WORK?