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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