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Lee Kirksey, M.D. FACS
Varicose Vein Questionaire 
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VARICOSE VEIN/SPIDER VEIN QUESTIONNAIRE



Name:


Email:

Please select all that apply:



1. Which of the following do you have:

 

Varicose veins (bulging, twisted, rope-like veins)

Spider veins (fine veins on skin surface)

Both varicose and spider veins

Don't know


2. Please circle if you are allergic to:

    

Topical Iodine

Local anesthetic
(xylocaine)

Tape (if so, is paper tape okay?)


3. Do you have a family history of varicose veins? Yes No

Who:

4. Do you have a family history of blood clots?

 Yes No Who:

Did he/she have the blood clot after major surgery?

 Yes No

If no, what circumstances was it under:

5. How many years have you had varicose or spider veins?
6. What is your occupation?

7. Please check any vein treatment

compressive stockings:

pantyhose, thigh highs, or knee highs

Prescriptive or Over-the-counter

How often & since when:

sclerotherapy (injection): saline / other medication

vein stripping: which leg: Right Left

when:

incision at groin: Yes No Don't know

 

other incision location:

local varicose vein removal/excision laser

(where, with whom)

8. Do you now have or have you had:

Unsightly veins

 Right Left

Aches and pains in legs

Right Left

Heaviness or tired legs

 Right Left

Ankle swelling

 Right Left

Itching in legs

 Right Left

Night cramps

Right Left

Bleeding from the veins

Right Left

Pigmentation (discoloration)

 Right Left

Dermatitis (eczema)

Right Left

Ulceration in legs

Right Left

Which leg hurts more?

Right Left

 

9. What activities cause your leg pain and what brings relief?

10. Most insurance require documentation of analgesic when considering coverage for varicose vein treatment. Please list any medication you have even taken for leg ache including prescriptive and over-the-counter medicine (Example: Tylenol, Motrin, Aleve, ibuprofen, & others)

11. I exercise: Daily regularly 2-3 x week seldom
12. Do you currently
have or had history of:

Blood Clots
(that required blood thinner) 		Yes No Right Left
  Superficial phlebitis
(clots in surface veins)		 Yes No Right Left
  Pulmonary emboli
(blood clots in lung) 		Yes No Right Left
  Diabetes Yes No    
 

Congestive Heart Failure (CHF)

 Yes No    
 

Vascular surgery

 Yes No    
 

Heart or bypass surgery

 Yes No    
 

Recent leg trauma

Yes No    

Revised: 4/2008

 
   

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