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VARICOSE VEIN HELPLINE
855-551-VEIN
(8346)
RISK ASSESSMENT FOR VARICOSE VEINS
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Name
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First
Last
Email
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Phone Number
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Doctor
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Age
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Less than 13
13-18
19-25
26-35
36-50
Over 50
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Address
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Do you have visible varicose veins?
Does the sight bother you?
Are your legs tired or achy?
Any prolonged sitting / standing?
Regular long distance travel?
Are you pregnant?
Select any that apply to you
If your answer is YES to any of the above, you are at risk. Please submit the form and the office will call you back.
Submit
PELVIC PAIN OR DISCOMFORT?
Pelvic congestion syndrome is the cause of pelvic pain or pelvic discomfort in approximately 20 – 30% of females. However it is rarely diagnosed. Therefore to help patients who think that they might have Pelvic Congestion Syndrome, we have designed this free online Pelvic Congestion Syndrome screening questionnaire which will give you some indication as to whether you might have Pelvic Congestion Syndrome or not.
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Name
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First
Last
Email
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Phone Number
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Do you suffer from any of the following?
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Aching or "Dragging" feeling in the pelvis on standing or sitting?
Irritable Bladder
Irritable Bowel
Deep pain or discomfort during sexual intercourse
Deep pain or discomfort after sexual intercourse
Backache
Abnormal bleeding during menstruation
Depression or feeling low because of your symptoms
Vaginal discharge
Tender lower abdomen
Swelling of the vagina or vulva
Varicose veins of the vulva or vagina
Varicose veins around your buttocks or very top of inner thighs
Haemorrhoids
If so are...
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your symptoms worse at the end of the day?
your symptoms worse before the onset of menstruation?
your symptoms eased when you lie down?
Have you had children?
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Yes
No
Thanks for filling the form in, the office will contact you soon.
Submit
Please complete the screening questionnaire below to help determine if you have the symptoms of peripheral arterial disease, or PAD
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1. Do you experience aching, cramping or pain in your legs, thighs or buttocks when you walk or exercise?
2. If yes, does the pain subside with rest?
3. Are your toes pale, discoloured or bluish?
4. Are your feet cold to the touch?
5. Do you have any sores or ulcers on your legs or feet that don't heal?
6. Do you have difficultly controlling your blood pressure on more than 3 blood pressure medications?
7. Do you have a personal history of high blood pressure, diabetes or aortic aneurysm?
8. Do you have a family history of high blood pressure, diabetes or aortic aneurysm?
9. Have you ever experienced a stroke, mini-stroke or transient ischemic attach (TIA)?
First Name
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No
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Yes
No
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Yes
No
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Yes
No
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Yes
No
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Yes
No
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Yes
No
Last Name
*
Address
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City
State
Zip Code
Country
Phone Number
*
Age
*
Email
*
Thank you for filling the form in, the office will be in contact soon!
Submit
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Home
Our Team
Meet Dr. Omotoso
Ask Dr. O
Our Team
Our Vision
Services
Services
Leg Wellness Clinic - Compression Stockings
The Venefit Procedure
Sclerotherapy
Venous Ultrasound
Financing
FAQ's
Image Gallery
Contact Us
