Vein Screening Assessment

1. Have you ever been diagnosed with varicose veins? *
YesNo

2. Have you had treatment for varicose veins? *
YesNo

3. Do you have a family history of varicose veins/venous reflux? *
YesNo

4. Do you have ankle swelling with prolonged standing/sitting or air travel? *
YesNo

5. During pregnancy, did you have leg swelling or bulging leg veins? *
YesNo

6. Please check the boxes next to any of the following leg symptoms you experience: *
PainCrampingRestless LegsBulging VeinsOpen Wounds or SoresHeavinessAchinessBurning or ItchingSwellingSkin Discoloration