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