COMPLIMENTARY ONLINE VEIN SCREENING

Your Name (required)

Your Email (required)

Your Phone

Your Zip Code

Gender:

1. Do you have leg pain? (required)
OccasionallyDailyLimits ActivityNone

2. Do any of the following conditions apply to you? (required)
DiabetesHigh Blood PressureHeart FailureCurrently SmokeNone

3. Do you use compression stockings? (required)
IntermittentUse Most DaysContinuallyNone

4. Do you have swelling of the ankle or leg? (required)
By MorningBy AfternoonBy EveningNone

5. Have you ever had a blood clot in your legs or lungs? (required)
YesNo

6. Have you ever had a history of blood clots in the veins? (required)
YesNo

7. Do you have visible varicose veins? (required)
YesNo

8. Have you had a heart attack or heart failure? (required)
YesNo

9. Have you had major surgery lasting over an hour in the last month? (required)
YesNo

10. Do you use birth control pills or estrogen replacement therapy? (required)
YesNo

11. Are you pregnant or had a baby within the last month? (required)
YesNo

12. In the last month, if you have felt pain in the legs, what was the intensity of this pain? (required)
No PainLight PainModerate PainIntense Pain

13. During the past month, to what extent did you feel limited in your ability to carry out daily activities because of your leg problems? (required)
Not Bothered or LimitedA Little BotheredModerately BotheredVery BotheredExtremely Bothered

14. During the past month, how often have you slept badly because of your leg problems? (required)
NeverSeldomFairly OftenVery OftenEvery Night

15. Please check the condition below that correspond to the condition of your legs. (required)
No visible signs of venous diseaseSpider veins, reticular veins, malleolar flareVaricose VeinsSwelling without skin changesChronic skin changes (pigmentation, eczema, thickened skin)Chronic skin changes with healed ulcerationChronic skin changes with active ulceration