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Many people complain of leg pain. This survey is designed to help you and us evaluate if you may be suffering from venous insufficiency and if you might benefit from vein treatments.

    Medical History

    Select the answer that best suits your health history.

    1. Does anyone in the family have a history of vein disease?
    1 – Myself2 – Parent3 – Sibling4 – None
    2. Is there family history of bleeding or clotting disorders?
    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

    Quality of Life with Venous Insufficiency

    Please consider whether you have experienced the following symptoms described in each sentence below and answer on a scale of 1 – 5.

    Select 1 if the symptom, sensation or discomfort described does not apply to you. Select 2, 3, 4 or 5 if you have felt it to a greater or lesser extent.

    During the past four weeks:

    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

    During the past four weeks, how much trouble have you had carrying out the actions and activities listed below because of your leg problems?

    7. Remaining standing for a long time
    1 – No Trouble2 – Slight Trouble3 – Moderate Trouble4 – Considerable Trouble5 – Could Not Do It
    8. Crouching / kneeling down
    1 – No Trouble2 – Slight Trouble3 – Moderate Trouble4 – Considerable Trouble5 – Could Not Do It
    9. Walking up an incline or stairs
    1 – No Trouble2 – Slight Trouble3 – Moderate Trouble4 – Considerable Trouble5 – Could Not Do It

    Early detection helps minimize disease progression and complications. Help us identify your condition using the following photos.

    10. Choose the best representation of your legs from the images below.

    Spider VeinsSpider Veins
    Varicose VeinsVaricose veins
    Skin ChangesSkin Changes
    Venous UlcerationVenous ulceration

    Thank you for taking our survey!

    Someone from our friendly staff will reach out to you shortly. In the meantime, please feel free to Contact Us with any questions or concerns.