Patient Vein Assessment Form – Hudson Pro Health Vein Center

Vein Health Screening Questionnaire to help determine risk for Chronic Venous Insufficiency (CVI).

Step 1 of 2 – Step 1: Symptoms

Are You at Risk for Chronic Venous Insufficiency?

Vein Health Screening Questionnaire

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Chronic Venous Insufficiency (CVI) is a condition that affects how blood flows through the veins in your legs. Please answer the questions below to help us determine whether you may benefit from a vein evaluation.

1. Daily Activity

1. Does your job or daily activity require you to stand or sit for long periods of time?

2. Leg Symptoms

2. Do you have swelling in your legs, especially after prolonged standing or sitting?(Required)
3. Do you experience aching, heaviness, cramping, or discomfort in your legs?(Required)
4. Do you have visible bulging/varicose veins or spider veins?(Required)
5. Do you have any skin discoloration or changes around your lower legs or ankles?(Required)
6. Do you have any sores or ulcers on your legs or ankles that are slow to heal?(Required)

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