Name

Email

Date

Age

Sex

Have you ever had vein stripping surgery?

Do you experience any of the following?

Other?

Do you experience these problems in just one, or both legs?

Do you take any medication for pain (eg, advil, etc.)?

If yes, what medication and how often?

Do you elevate your legs to relieve discomfort?

Do you wear support hose prescribed by a doctor?

If yes, how long have you worn them?

Do you have any problem walking?

If yes, how does it affect you?

Do you stand much at work?

Do you stand much at home?

Have you ever had any test (s) done on your veins?

If yes, when, what type test and where on the leg?

Were you diagnosed with saphenous vein reflux?