Online Vein Survey

1. Does anyone in the family have a history of vein disease?
1 – Myself2 – Parent3 – Sibling4 – None

2. Is there family history of blood clots?
1 – Myself2 – Parent3 – Sibling4 – None

3. Have you previously been treated for vein disease?
1 – No2 – Recently3 – Over 3 years ago4 – More than 5 years ago

4. Have you had any pain in your ankles or legs, and how severe has this pain been?
1 – No Pain2 – Slight Pain3 – Moderate Pain4 – Considerable Pain5 – Severe Pain

5. Do you have swollen ankles?
1 – Never2 – Rarely3 – Fairly Often4 – Very Often5 – Every Day

6. Have you slept poorly because of your pain, cramps, burning, itching or restless legs, and how often?
1 – Never2 – Rarely3 – Fairly Often4 – Very Often5 – Every Night

7. Do you have trouble remaining standing for a long time?
1 – No Trouble2 – Slight Trouble3 – Moderate Trouble4 – Considerable Trouble5 – Could Not Do It

8. Do you have trouble with walking or exercise?
1 – No Trouble2 – Slight Trouble3 – Moderate Trouble4 – Considerable Trouble5 – Could Not Do It

9. How often do you use pain medication for leg pain?
1 – Never2 – Rarely3 – Fairly Often4 – Very Often5 – Every Day