About Us
About Us
Assessment Questionnaire
Please assist us by completing the following questionnaire AND SUBMITTING to SIWVC at your earliest convenience.
Name
*
First Name
Last Name
Male
Female
Date of Birth
MM
DD
YYYY
What are you concerned about?
Both Legs
Left Leg
Right Leg
Spider / Thread Veins
Varicose Veins
Both Spider and Varicose Veins
What symptoms do you have? (Please tick)
Appearance/cosmesis
Heaviness
Bleeding
Pain
Restless Legs
Problem is getting worse
Burning
Leg Cramps
Legs ache with menstruation
Stinging
Itching
Ulceration
Aching
Swelling of the ankle/s or Leg/s
Brown pigmentation in the skin
Throbbing
Cellulitis
Other (please specify)
Height
Weight
Do you partake in regular exercise?
Yes
No
If Yes, what type of exercise do you do?
How many days per week?
Do You Smoke?
Yes
No
If Yes, How many per day?
Pregnancies (How many)
Children (how many)
Miscarriages (how many)
Pill / HRT
Do you have a family history of varicose veins? Who?
What is/was your occupation?
Does/did your occupation involve standing for long periods?
Yes
No
When did your veins start to become a problem?
Have you ever had sclerotherapy for your varicose veins? (Please give details)
Have you ever had laser ablation or surgery for your varicose veins? (Please give details)
Do you have a history of clotting disorders or deep vein thrombosis (DVT)?
General health: Have you suffered from? (Please tick)
Migraine
Asthma
Hepatitis A,B or C
Eczema
Leg ulcers
HIV/Aids
Heart Disease
Arterial disease
Regular Medications
Allergies
Any hospital admissions/operations
Other illnesses past / present (please list)
Please write down any questions or concerns you wish to bring to the doctor’s attention during the consultation
Do you give permission for an ultrasound examination of your leg veins?
Yes
No
Thank you!
Thank you for answering these questions.
