Self-Assessment Form

Please take this self-assessment to see if you might be a candidate for additional screening for potential varicose veins and / or chronic venous insufficiency.

Have you ever had varicose veins?
 Yes No

Do you experience leg pain, aching or cramping?
 Yes No

Do you experience leg or ankle swelling, especially at the end of the day?
 Yes No

Do you feel “heaviness” in your legs?
 Yes No

Do you experience restless legs?
 Yes No

Do you have skin discoloration or texture changes?
 Yes No

Do you have open wounds or sores?
 Yes No

Has anyone in your blood-related family ever had varicose veins or been diagnosed with venous reflux disease or chronic venous insufficiency?
 Yes No

Have you had any treatments of procedures for vein problems?
 Yes No

Do you stand for long periods of time, such as at work?
 Yes No

Self-Assessment Results

If you answered yes to one or more of the above questions, please contact us for a consultation to see if you may be candidate for venous reflux disease.