Venous Health History Survey

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Have you ever had vein stripping surgery? 

Do you experience any of the following in your legs:     

Aching/pain?           

Heaviness?              

Tiredness/fatigue?   

Itching/burning?      

Swollen ankles?      

Leg cramps?           

Restless legs?         

Throbbing?              

Varicose Veins?      

Do you experience these problems in just one or both legs? 

Do you take any medication for pain (i.e., Advil, etc.)?              

Do you elevate your legs to relieve discomfort?  

Do you wear support hose prescribed by a doctor?  

Do you have any problem walking?   

Do you stand much at work?   

Do you stand much at home?   

Have you ever had any test (s) done on your veins?     

Have you been diagnosed with saphenous vein reflux?