Do you perform a predominantly standing and / or sitting job?
Yes
No
Are you overweight (BMI > 30)?
Yes
No
Does anyone in your family suffer from leg conditions, such as varicose veins?
Yes
No
Are you pregnant?
Yes
No
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Questions 5-8
Are you over 50 years old?
Yes
No
Do you take hormone preparations, e.g. the pill or preparations to ease the menopause?
Yes
No
Have you recently had an operation on your legs?
Yes
No
Have you noticed any changes in your legs (e.g. spider veins or tightness, etc.)?
Yes
No
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Questions 9-12
Has your skin on the lower leg or ankle changed (e.g. eczema or color changes etc.)?
Yes
No
Do you have spider veins on your legs?
Yes
No
Do you have varicose veins?
Yes
No
Have you ever been diagnosed with phlebitis?
Yes
No
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Questions 13-16
Do you suffer from evening swellings on your ankle?
Yes
No
Do your symptoms improve when you elevate your legs (e.g. less pain, reduction of leg swelling, etc.)?
Yes
No
Have you ever had a thrombosis?
Yes
No
Do you currently have or have you ever had an active ulcer or open wound?
Yes
No
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