Chronic Venous Insufficiency: Patient Self-Assessment

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? O  Yes O  No


Signs and Symptoms

Do you experience any of the following signs and symptoms in your legs or ankles?

Do you experience leg pain, aching or cramping? O  Yes O  No
Do you experience leg or ankle swelling, especially at the end of the day? O  Yes vO  No
Do you feel “heaviness” in your legs? O  Yes O  No
Do you experience restless legs? O  Yes O  No
Do you have skin discoloration or texture changes? O  Yes O  No
Do you have open wounds or sores? O  Yes O  No


Risk Factors

Has anyone in your blood-related family ever had varicose veins or been diagnosed with venous reflux disease or chronic venous insufficiency? O  Yes O  No
Have you had any treatments or procedures for vein problems? O Yes O No
Do you stand for long periods of time, such as at work? O Yes O 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 developing venous reflux disease.