Vein and Vascular Assessment

Contact Info

Patient Name

Email

Phone (optional)

Preferred Contact

Phone Email

Questionnaire

1. Do you experience pain, aching, pressure, burning or discomfort in your legs or ankles?

NoYes

Where do you feel these symptoms?

Legs Ankles

Which symptoms apply?

Pain Aching Pressure Burning Discomfort

2. Do you experience cramping/tightening in your legs?

NoYes

3. Do you have Varicose Veins that cause discomfort?

NoYes

4. Do you experience swelling in your legs or ankles?

NoYes

5. Do your legs feel restless?

NoYes

6. Do your symptoms get worse when you stand or sit?

NoYes

7. Have you experienced any ulcers, wounds or sores?

NoYes

8. Have you experienced discoloration/darkening of the skin on your legs, ankles or feet?

NoYes

9. Do you wear or have your worn any compression hose in the past?

NoYes

10. Have you ever been treated or seen by another doctor for your veins?

NoYes

When was your last appointment with the doctor who treated you previously?

What procedure did the previous doctor perform?

11. Have you ever been told you have venous insufficiency?

NoYes

12. Do these symptoms affect your daily life/work/sleep?

NoYes

Acknowledgment of Authorization

By submitting the information requested on this form, you are authorizing Citrin Cardiology LLC to store and/or print the answers and to contact you/the patient by email (or phone if provided).