Many people complain of leg pain. We would like to find out how often these leg problems occur and to what extent they affect the everyday lives of those who have them. Please consider whether you have experienced the following symptoms described in each sentence below and answer on a scale of 1 – 5.

Quality of Life with Venous Insufficiency

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:

1. 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
2. How much trouble have you had at work or with your usual activities because of your leg problems?
1 – No Trouble2 – Slight Trouble3 – Moderate Trouble4 – Considerable Trouble5 – Severe Trouble
3. Have you slept poorly because of your leg problems, 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?

4. Remaining standing for a long time
1 – No Trouble2 – Slight Trouble3 – Moderate Trouble4 – Considerable Trouble5 – Could Not Do It
5. Climbing several flights of stairs
1 – No Trouble2 – Slight Trouble3 – Moderate Trouble4 – Considerable Trouble5 – Could Not Do It
6. Crouching / kneeling down
1 – No Trouble2 – Slight Trouble3 – Moderate Trouble4 – Considerable Trouble5 – Could Not Do It
7. Walking at a brisk pace
1 – No Trouble2 – Slight Trouble3 – Moderate Trouble4 – Considerable Trouble5 – Could Not Do It
8. Travelling by car, bus, or plane
1 – No Trouble2 – Slight Trouble3 – Moderate Trouble4 – Considerable Trouble5 – Could Not Do It

Leg problems can also affect your spirits. How closely do the following statements correspond to how you have felt during the past four weeks?

9. I got tired quickly
1 – Not At All2 – A Little3 – Moderately4 – A Lot5 – Completely
10. I felt embarrassed about showing my legs
1 – Not At All2 – A Little3 – Moderately4 – A Lot5 – Completely
11. I felt as if I was handicapped
1 – Not At All2 – A Little3 – Moderately4 – A Lot5 – Completely
12. I found it hard to get going in the morning
1 – Not At All2 – A Little3 – Moderately4 – A Lot5 – Completely

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.