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Phone: (440) 782-6054

Venous Health History Form






Male
Female


Yes
No


Aching/pain in your legs?
Heaviness?
Tiredness/fatigue?
Itching/burning?
Swollen ankles?
Leg cramps?
Restless legs?
Throbbing?



One Leg
Both Legs


Yes
No



Yes
No


Yes
No



Yes
No



Yes
No


Yes
No


Yes
No