Forms To Complete for Your Appointment

Please download and complete these forms and bring into the office the day of your procedure.

Self Assessment: Determine Your Need for Additional Screening

Please take this self-assessment to see if you might be a candidate for additional screening for potential varicose veins and / or chronic venous insufficiency. Click here to download assessment.

History

  • Have you ever had varicose veins? Yes No

Signs and Symptoms

  • Do you experience leg pain, aching or cramping? Yes No
  • Do you experience leg or ankle swelling, especially at the end of the day? Yes No
  • Do you feel “heaviness” in your legs? Yes No
  • Do you experience restless legs? Yes No
  • Do you have skin discoloration or texture changes? Yes No
  • Do you have open wounds or sores? Yes No

Risk Factors

  • Has anyone in your blood-related family ever had varicose veins or been
    diagnosed with venous reflux disease or chronic venous insufficiency? Yes No
  • Have you had any treatments of procedures for vein problems? Yes No
  • Do you stand for long periods of time, such as at work? Yes No

Self-Assessment Results

If you answered yes to one or more of the above questions, please contact us for a consultation to see if you may be candidate for venous reflux disease.

Contact Pura Vida Vein Center at 402-493-7873.