Vein screening Questionnaire – to be completed prior to the consultation

• Do you have bulging or varicose veins?

yes           no

• Do your legs feel heavy, tired or achy – especially at the end of the day?

yes            no

• Do your legs feel better with rest and elevation?

yes           no

• Do your legs swell at the end of the day?

yes           no

• Do you experience leg fatigue, fullness, “heavy legs” after prolonged standing or sitting?

yes           no

• Do your legs feel better in the morning compared to evening ?

yes           no

• Do you have cramps or “restless leg “

yes           no

• Is the skin below your knees darker in color or hard?

yes           no

• Have you ever had an ulcer or open sore on your lower leg?

yes           no

• Have you had an infection in your leg ?

yes           no

• Has anyone in your family ever had varicose veins or been diagnosed with chronic venous insufficiency ?

yes           no

• For women: have you ever been pregnant?Multiple pregnancies?

yes           no

• Have you had any treatments or procedures for vein problems? If so, what treatment(s) or procedure(s)? Can you provide copies ?

yes           no

• Have you ever worn compression stockings ? For more than 3 months ?

yes           no