Vascular History Questionnaire

What is Venous Screening? Venous screening is the assessment that will help determine how at risk you are for developing Venous Disease. Few people are aware of the serious problems that can develop in the veins. Knowing your risk factors can help your doctor diagnose you and help you and your doctor decide which treatments are right for you, and may even save your life when the prevention of venous thrombolism is applied. Are you at risk for…

  • Blood clots?
  • Pulmonary Embolism?

Do you have…

  • Varicose or spider veins?
  • Leg pain?
  • Leg swelling?

Did you know….

  • Dangerous blood clots form in the leg veins of millions of Americans each year.
  • These blood clots can break loose and travel to the lungs, killing an estimated 100,000-180,000 Americans each year.
  • 10 – 35% of adults have leg veins that do not work properly.
  • Half a million Americans have ulcers in their legs caused by diseased veins.

Get Screened! Abella Heart forum has created screening programs to educate the public about DVT, risk factors, prevention and treatment options. These programs will assess the risk factors of all participants, and provide education to each person.



VASCULAR HISTORY: (please check all that apply)

Do you have or have you ever been diagnosed with:


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Do you experience any of the following in your legs?


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Which of the following do you currently do to improve your leg vein symptoms?


YESNO


YESNO


YESNO

FAMILY HISTORY:
Has any member of your family (not to include spouse or in-laws) ever had the following conditions. If yes, indicate family member.


YESNO


YESNO


YESNO


YESNO


YESNO

VEIN TREATMENT HISTORY:
Have you ever been treated for varicose veins with the following?


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PERSONAL ACTIVITIES LIST:
(please check all that apply)


YESNO


YESNO


YESNO


YESNO


YESNO