Varicose Vein Questionnaire Form
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1VARICOSE VEIN QUESTIONNAIRE
This form must be completed in full prior to your consultation.
PATIENT NAME: ____________________________________________________ DOB: ________________ DATE: ________________
1. Do you experience any of the following symptoms? (Circle your answers)
a.
Aching/ pain in your legs?
YES
NO
b. Heaviness in your legs?
YES
NO
c.
Tiredness/ fatigue?
YES
NO
d. Itching/ burning?
YES
NO
e. Swollen ankles/legs?
YES
NO
f.
Leg Cramps?
YES
NO
g.
Restless legs?
YES
NO
h. Throbbing?
YES
NO
i.
Other? __________________________________________________________________________________________
2. Have your veins gotten worse in recent months?
YES
NO
If yes, explain: ___________________________________________________________________________________________
3. Do you take any medication for pain (i.e. Advil, Aleve, etc…)?
YES
NO
If yes, explain: ___________________________________________________________________________________________
4. Do you elevate your legs to relieve discomfort?
YES
NO
5. Do you wear support stockings/compression socks?
YES
NO
If YES:
a.
Were they prescribed by a doctor?
YES
NO
b. What strength? (15‐20mmHg, 20‐30mmHg, etc.) _______________________________________________________
c.
Do they provide relief?
YES
NO
d. How long have you been wearing them consistently? ____________________________________________________
6. Do you have problems with walking due to vein pain?
YES
NO
7. At work do you stand most of your day?
YES
NO
a.
At home?
YES
NO
8. Do you have problems with doing the following tasks?
a.
Doing the dishes?
YES
NO
b. Dressing?
YES
NO
c.
Bathing?
YES
NO
d. Daily meal prep?
YES
NO
9. Have you ever had any tests or procedures done on your veins?
YES
NO
If yes, when, what type of test/procedure and what location on the leg?
________________________________________________________________________________________________________
10. Have you been diagnosed with saphenous vein reflux?
YES
NO
11. Do you experience repeated incidence of:
a.
Surface vein inflammation/swelling?
YES
NO
b. Bleeding from your vein?
YES
NO
c.
Non‐healing wounds on your legs?
YES
NO
d. Stasis dermatitis (darkening of the skin in the legs)?
YES
NO
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Parent category: Life