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.