Murray Hill Plastic Surgery Varicose Vein Questionnaire 2023
Chronic Venous Insufficiency (commonly known as CVI or varicose veins) is a common circulation problem in which the valves in the veins in the legs (vessels carrying the blood back to the heart) become weakened and non-compliant. Please fill out this questionnaire to see if you have symptoms of Chronic Venous Insufficiency. Once we receive your completed questionnaire, we will contact you if are qualified for a vein screening. Thank you!
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Email *
Name *
Phone Number *
Date of Birth *
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Do you experience pain in your legs when walking?
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Do you have noticeable distended veins?
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Required
 Do you have varicose veins or spider veins?
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If you answered YES to the question above, where is the location of your varicose veins/spider veins?
Do you have swelling in your legs?
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 Do you have swelling in the morning?
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Do you have Diabetes?
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Do you have any painful sores or ulcers on your legs or feet that are not healing?
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Have you ever had surgery to your veins in your legs, vein removal for open heart surgery, vein stripping in your legs, or cosmetic vein repair?
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Have you ever had a blood clot in your legs (DVT or Deep Vein Thrombosis)?
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Does your job or daily activity require standing for long periods of time?
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Do you have any risk factors listed below?
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Required
Have you ever had a test on your legs (blood pressure cuffs on your ankles) sometimes called a PVR?
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Have you ever had a venous sonogram (also called venous Doppler)?
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If you answered YES to the question above, when did you have your venous sonogram (also called venous Doppler)?
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