Patient Self-Assessment

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.

History

  • Have you ever had varicose veins?

Signs and Symptoms

Do you experience any of the following signs and symptoms in your legs or ankles?

  • 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?

Risk Factors

  • 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?

Self-Assessment Results

If you answered yes to one or more of the above questions, please contact us for a consultation to see if
you may be candidate for venous reflux disease.