Self-Assessment


History Yes No

1. Do you have varicose veins? (Varicose veins are large, bulging veins as opposed to spider veins, which are thin, branching veins that lie just beneath the skin surface.)

Symptoms Yes No

2. Do you experience any of the following symptoms in your legs, ankles, or feet?

Leg pain, aching or cramping

Burning or itching of the skin

Leg or ankle swelling

"Heavy" feeling in legs

Skin discolorations or texture changes, such as above the inner ankle

Open wounds or sores, such as above the inner ankle

Restless Legs

Risk Factors Yes No

3. Does anyone in your blood related family have varicose veins or been diagnosed with venous reflux?

4. Have you had any treatments or procedures for your vein problems?

5. Has anyone in your blood related family had vein stripping?

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

7. Do you frequently engage in heavy lifting?

8. Have you had multiple pregnancies?

Text Size: Decrease Text Size Increase Text Size

Patient Information

Locate a Physician Near You

Please enter a valid email address and zip code.
Email:   
Zip:   
 I agree to the terms and conditions
  Yes, please notify me of future
vein screening events in my area

What Patients are saying...

open quoteThere is very little discomfort. [Vein stripping] is no comparison whatsoever, this is good.close quote - Margaret S. (Bristol, England) View full story  |  Read more testimonials