Venous Reflux Screening

Answer the following questions to help us determine if you may be experiencing venous insufficiency.

Questionnaire

Do You Need To Make An Appointment For Varicose Veins?

Venous Reflux Screening

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Do you experience heaviness, tired or weak legs?*
Do you have burning or itching in your legs?*
Do you have swelling in your ankles and legs?*
Do you have poorly healing wounds or skin ulcers?*
Do you have a family history of varicose or spider veins?*
Are you seeing discoloration in your skin or texture changes?*
Are you experiencing restless leg syndrome?*
Are you pregnant?*
Does your work require standing or sitting for long periods of time?*
Have you ever had blood clots?*

Please provide the following information so we can contact you upon review of your responses:

e.g. name@example.com
e.g. (555) 555-5555
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