Self Assessment

Self-Assessment

This self-assessment survey is intended to help better understand your symptoms and risk factors for venous disease.  Once you submit a completed survey, a member of our staff will contact you within 1-2 business days to schedule a free consultation appointment with a CVD network physician.

History

Varicose veins are large, bulging veins, as opposed to spider veins, which are thin veins just beneath the skin's surface. Have you ever had varicose veins?*

Signs And Symptoms

Do you experience or suffer from any of the following signs or symptoms in you legs?








Risk Factor

Has anyone in your blood-related family ever had varicose veins or been diagnosed with venous disease?

Have you had any treatments or procedures for vein problems?

Do you sit or stand for prolonged periods of time?

Do you exercise regularly?

Do you smoke?

Have you ever been pregnant?

Leg Photos (Optional)

To help the CVD staff to better serve you, we are requesting that a photo of your legs be uploaded and submitted with your self-assessment survey. Please provide a full front photo and a full back photo of each leg (2 photos per leg) in natural light with your smart phone, tablet, or quality digital camera. Easily submit the photos using the upload tool.


Acceptable file types: doc,docx,pdf,txt,gif,jpg,jpeg,png.
Maximum file size: 1mb.

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