Test page Vein Assessment Form Have you ever been diagnosed with varicose veins? Yes No Have you had treatment for varicose veins? Yes No Do you have a family history of varicose veins/venous reflux? Yes No Do you have ankle swelling with prolonged standing/sitting or air travel? Yes No During pregnancy, did you have leg swelling or bulging leg veins? Yes No Please check the boxes next to any of the following leg symptoms you experience: Pain Achiness Swelling Bulging Veins Cramping Heaviness Burning or itching Skin discoloration or texture changes Restlessness Open wounds or sores Someone in our office will contact you regarding your vein assessment.Full Name* Phone Number*Email* CAPTCHANameThis field is for validation purposes and should be left unchanged. Δ Have you ever been diagnosed with varicose veins? Yes No Have you had treatment for varicose veins? Yes No Do you have a family history of varicose veins/venous reflux? Yes No Do you have ankle swelling with prolonged standing/sitting or air travel? Yes No During pregnancy, did you have leg swelling or bulging leg veins? Yes No Please check the boxes next to any of the following leg symptoms you experience: Pain Achiness Swelling Bulging Veins Cramping Heaviness Burning or itching Skin discoloration or texture changes Restlessness Open wounds or sores Someone in our office will contact you regarding your vein assessment.Full Name* Phone Number*Email* CAPTCHAEmailThis field is for validation purposes and should be left unchanged. Δ