Varicose Veins Questionnaire
Please answer each of the questions below.

More information about Varicose Veins:
https://www.sirweb.org/patient-center/varicose-veins/

First Name *
Your answer
Last Name *
Your answer
Phone Number *
Your answer
Email Address *
Your answer
1. Gender *
2. Race *
3. Date of Birth *
MM
/
DD
/
YYYY
4. Height in Feet and Inches (example: 5'4") *
5. Weight (Pounds) *
Your answer
6. Do you have a history of Varicose Veins in your family? *
7. Have you been pregnant in the last 2 years? *
8. Do your daily activities consist of long periods of sitting or standing? *
9. Have you recently suffered trauma to your legs? *
10. Have you noticed changes in skin color around your ankles or legs? *
11. Do you feel heaviness, fullness, aching or pain in your legs? *
12. Have you noticed skin sores (ulcers) on your legs? *
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