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Venous Health History

It will only take a few minutes to review the Venous Health History Survey. For your convenience we have included the PDF version as well, which you may print and review at a later point to your convenience. If you think the answer is 'yes' to even a few questions then call us immediately to schedule your appointment to further explore your Venous Health History in greater detail with our experienced and knowledgeable Health Providers.

You may reach us via:           

Tel:  (937) 979-1038   

Fax: (937) 979-1037


We look forward to hearing from you!


Venous Health History Survey

Have you ever had vein stripping surgery? 

Do you experience any of the following in your legs:     





Swollen ankles?      

Leg cramps?           

Restless legs?         


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?            

Venous Health History Form

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