1. Do you have bulging or varicose veins?
*
Yes
No
2. Do your legs feel tired or ache at the end of each day?
*
Yes
No
3. Do you have leg swelling?
*
Yes
No
4. Is the skin below your knees darker in color or feel hardened?
*
Yes
No
5. Do you have any open sores or skin ulcers?
*
Yes
No
6. Do you stand each day for long periods of time?
*
Yes
No
7. Have you been advised to wear compression stockings?
*
Yes
No
8. Have you ever had a thrombus or blood clot? (DVT)
*
Yes
No
9. Have you been treated for or had vein procedures?
*
Yes
No
10. Do you have any direct family history of varicose veins, venous insufficiency or venous reflux?
*
Yes
No
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