Vein Assessment Form
Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
Email
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Sex
Female
Male
How did you hear about us?
Primary Care Doctor or OBGYN
Insurance Provider
Have you ever been diagnosed with:
Varicose vein problems
Phlebitis (vein redness/tenderness
Blood Clots
Deep Vein Thrombosis (DVT)
Saphenous Vein Reflux
Please specify which leg:
Which of the following do you experience in your leg(s)?
Aching/pain
Heaviness
Tiredness/fatigue
Itching/burning
Swelling
Cramps
Restless Legs
Throbbing
Skin or ulcer problems
Other
Please specify which leg:
Have you ever been treated for varicose veins with:
Sclerotherapy
Laser therapy (spider veins)
Phlebectomy
Vein Stripping Surgery
RF Abation (VNUS Closure)
Please specify which leg:
Which of the following do you currently do to improve your leg systems?
Medication for pain
Elevation of legs
Wear support hose
Which of the following does your work require?
Prolonged standing periods
Prolonged sitting periods
Do you exercise regularly?
Do you smoke?
Are you pregnant/have you ever been?
Other Notes:
Send Form
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