Patient First Name

Patient Last Name

Date of birth

Do you experience any of the folloiwng in your leg(s)?

Aching/Pain in legs?

Yes

No

Left

Right

Heaviness in legs?

Yes

No

Left

Right

Tiredness/fatigue in legs?

Yes

No

Left

Right

Itching/burning in legs?

Yes

No

Left

Right

Swelling/Throbbing in legs?

Yes

No

Left

Right

Leg Cramps?

Yes

No

Left

Right

Restless leg issues?

Yes

No

Left

Right

Do you do any of the following to improve the discomfort in your leg(s)?

Take medication?

Yes

No

If so, what medication?

Elevate you legs?

Yes

No

Wear support hose?

Yes

No

Personal and Family History:

Does anyone in your family have Varicose Veins?

Yes

No

If so, who?

Have you ever been pregnant?

Yes

No

If so, how many times?

Do you sit or stand for long periods of time?

Yes

No

For how long?

Do you exercise regularly?

Yes

No

How often?

Do you have Insurance?

Yes

No

Insurance Carrier:

Member ID:

Group ID:

Captcha