ASSESSMENT QUESTIONNAIRE

Please assist us by completing the following questionnaire and return to SIWVC at your earliest convenience.

PATIENT DETAILS

First Name *

Last Name *

Date of Birth *

Gender

MaleFemaleOther

Patient Email *

Patient Phone *

What are you concerned about? *

Spider / Thread VeinsVaricose VeinsBoth Spider and Varicose VeinsBoth LegsLeft LegRight Leg

Other symptoms:

Height (cm) *

Weight (kg) *

Do you partake in regular exercise?

YesNo

If yes, what type of exercise do you do?

How many days per week?

General health: Have you suffered from? (Please tick)

Migraine Asthma Hepatitis A,B or CEczema Leg ulcers HIV/AidsHeart Disease Arterial disease

Do you Smoke? *

YesNo

If yes, how many (cigarettes/vape etc) per day:

Pregnancies (how many):

Children (how many):

Miscarriages (how many):

Are you currently pregnant or breastfeeding? *

YesNo

Are you currently on the Pill or HRT (Please give details):

Do you have a family history of varicose veins? Who?

What is/was your occupation?

Does/did your occupation involve standing for long periods?

YesNo

When did your veins start to become a problem?

MEDICAL DETAILS

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)?

What symptoms do you have? (Please tick)

Appearance/cosmesis Heaviness BleedingPain Restless Legs Problem is getting worseBurning Leg Cramps Legs ache with menstruationStinging Itching UlcerationAching Swelling of the ankle/s or Leg/s Brown pigmentation in the skinThrobbing Cellulitis

Please list any regular medications your are currently taking:

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? *

YesNo

Thank you for answering these questions.

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