eVein Screening - Precision Vein Center

eVein ONLINE SCREENING ASSESSMENT

The Precision Vein Center believes in both educating and personalizing the patient experience. Our online evaluation, eVein, allows you to confidentially submit your completed questionnaire directly to our clinical team. We will review and assess your responses and contact you directly to discuss our recommendations. During this discussion, together, we will determine whether or not you should consider an in-office varicose vein evaluation.

Are you experiencing?

spider veins or unsightly purple veins

varicose veins

leg swelling

achiness in the leg

leg pain

leg heaviness

leg cramps

restless legs

knotty or ropy veins in the legs

numbness or tingling in your feet

Which of the following improves your symptoms?

rest

compression hose

walking

Which of the following worsens your symptoms?

sitting

standing

lying down

walking

pregnancy

Which of the following treatments have you tried?

compression hose

anti-inflammatories

vein excisions or vein stripping

no previous treatments

Which statement most accurately describes how your legs feel?

Leg pain improves by the morning and gradually becomes more painful

Legs become achy and fatigued as the day progresses

Legs hurt more when I walk and are relieved when I sit down or stop walking, but the pain returns when I walk a similar distance again

Legs hurt or ache more when sitting for long periods, i.e. extended care ride or air travel.

Legs hurt or ache more when standing stationary, or still, for long periods of time.

No pain or discomfort, I just do not like the way they look.

Does anyone in your immediate or extended family have swollen legs, varicose veins or spider veins?

Yes

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I hereby release the screening physician and all other health care volunteers from all responsibility in connection with this screening process. I understand that this is just a screening for venous disease and does not constitute a complete or definitive diagnosis. Information gathered in this screening is strictly confidential and is being collected for review and preliminary determination of the likelihood of venous insufficiency existing in said participant. This form submits this data through email to Precision Vein unencrypted.

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