VEIN QUESTIONNAIREPlease fill out this questionnaire to see if you have symptoms of Chronic Venous Insufficiency commonly known as Varicose Veins. Do you have any visible Varicose, Spider or bulging veins? Yes No Do you have any of the following signs or symptoms? Leg fatigue or tiredness in the legs Leg heaviness Leg pain (caused by prolonged standing or sitting) Itching of the legs/feet Tingling in the legs/feet Swelling of the ankles Skin discoloration in the lower legs Open sores or ulcers on lower legs/ankles Is there a history of vein problems or blood clots in your family? Yes No I don't know Name * First Name Last Name Phone * (###) ### #### Thank you!