Bay Area Heart
Important!
Call 911
if you are experiencing any symptoms of a heart attack.
(832) 905-5940
infobah@qoroshealth.com
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Important!
Call 911
if you are experiencing any symptoms of a heart attack.
Surgical Center
Patient Portal
Menu
Home
About Us
our providers
MEDICAL SERVICES
HOSPITALS AND INSURANCES
Patient Resources
Patient forms
Testing Instructions
PATIENT EDUCATION
Blog
Contact
VEIN SCREENING
ASSESSMENT
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Date
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Secondary Insurance:
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Sex
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DOB
How did you hear about us?
HISTORY
Have you ever had varicose veins or bulging veins?
Yes
No
SIGNS AND SYMPTOMS
Do you experience any of the following in your legs or ankles?
Leg pain, aching or cramping
Burning or itching of the skin
Leg or ankle swelling, especially at the end of the day
“Heavy” feeling in legs
Varicose veins
Skin discoloration or texture changes, such as above the inner ankle
Open wounds or sores, such as above the inner ankle
Restless legs
RISK FACTORS
Has anyone in your family ever had varicose veins?
Yes
No
Have you had any treatments or procedures for vein problems?
Yes
No
Do you sit or stand for long periods of time, such as at work?
Yes
No
Do you frequently engage in heavy lifting?
Yes
No
Have you ever had varicose veins or bulging veins?
Yes
No
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