National Screening For Vascular Disease

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Are You at Risk for Venous Disease?

Your answers to these questions will help you know.

DO YOU HAVE:

Varicose veins (visibly enlarged, bulging veins beneath the skin)? Yes No
Spider veins (small, visible blood vessels in the skin which take on a blue or red color)? Yes No
Slow healing sores (ulcers) on your legs or feet? Yes No
Skin Changes in the lower legs (discoloration/thickening)? Yes No
Discomfort/heaviness/pain in your legs? Yes No
Swelling (right/left) (legs/ankles/feet)? Yes No
Need to wear support stockings(never/sometimes/always)? Yes No
Other vein problem (please explain)? Yes No
Does your job, lifestyle or health require you to sit,
stand or remain lying down for long periods of time?
Yes No

MEDICAL HISTORY

Did you experience injury or trauma to the affected area? Yes No
Do you have diabetes? Yes No
Do you smoke? Yes No
Have you ever smoked? Yes No
If female, have you ever been pregnant? Yes No

PAST SURGERIES

Previous varicose vein surgery? Yes No
Previous injections (sclerotherapy) of veins or spider veins? Yes No
Leg bypass surgery? Yes No
Heart bypass surgery? Yes No
Knee/hip surgery (replacement)? Yes No

FAMILY HISTORY
(Choose "Yes" or "No" as it applies to any family member)

Blood clots or phlebitis? Yes No
Varicose or spider veins? Yes No
History of vascular or bypass surgery? Yes No
Bleeding problems? Yes No
Diabetes? Yes No
 

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The higher your score, the more important it is for you to see your doctor. You and your doctor may wish to discuss your responses to this questionnaire.

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