Self Assessment Survey



Patient Self-Assessment

Please take this self-assessment to see if you might be a candidate for additional screening for potential varicose veins and / or chronic venous insufficiency.

If you answer “Yes” to any of these questions, contact our office at 732-846-7000 for a consultation to see if you may be a candidate for venous reflux disease. 


Have you ever had varicose veins?

Signs and Symptoms

  • Do you experience any of the following signs and symptoms in your legs or ankles?
  • Do you experience leg pain, aching or cramping?
  • Do you experience leg or ankle swelling, especially at the end of the day?
  • Do you feel “heaviness” in your legs?
  • Do you experience restless legs?
  • Do you have skin discoloration or texture changes?
  • Do you have open wounds or sores? 

Risk Factors

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

Have you had any treatments of procedures for vein problems?

Do you stand for long periods of time, such as at work? 

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