Have you ever had varicose veins? Varicose veins are large bulging veins, as opposed to spider veins, which are thin, branching veins just beneath the skin’s surface.
Yes
No
Signs and Symptoms
Do you experience any of the following signs and symptoms in your legs or ankles? (Click all that apply)
Leg pain, aching or cramping
Burning or itching of the skin
Leg or ankle swelling, especially at the end of the day
“Heavy” feeling in the legs
Varicose veins
Skin discoloration or texture changes such as above the inner ankle
Open wound or sores, such as above the inner ankle
Restless legs
Risk Factors
Has anyone in your blood-related family ever had varicose veins or been diagnosed with chronic venous insufficiency or venous reflux?
Yes
No
Do you stand for long periods of time, such as at work?
Yes
No
Do you frequently engage in heavy lifting?
Yes
No
Have you ever been pregnant?
Yes
No
Contact Information
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First Name
Last Name
Email
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Daytime Phone
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Format: (000) 000-0000.
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