Online Questionnaire

Download or Fill out the Online Questionnaire below!

Need more info about AMDS VEIN CARE? Check out this PDF brochure.

Online Questionnaire

– Print Questionnaire –

Name (required)

Date of Birth

Date

Home Phone

Upon submission of your quiz, our trained staff will review your answers and follow up with you. Our staff will review your results and should it be recommended, we will schedule a time for you to meet with our doctor. Outcome of this quiz is not a diagnosis.

  1. Do you experience pain in your legs when walking?
  2. Do you have swelling in your legs?
  3. Do you have swelling in the morning?
  4. Do you have Diabetes?
  5. Have you ever had a blood clot in your legs (DVT or Deep Vein Thrombosis)?
  6. Does your job or daily activity require standing for long periods of time?
  7. Do you have any painful sores or ulcers on your legs or feet that are not healing?
  8. Do you have noticeable distended vein?
    Where?
  9. Do you have varicose veins or spider veins?
    Where?
  10. Have you ever had surgery to your veins in your legs, vein removal for open heart
    surgery, vein stripping in your legs, or cosmetic vein repair?
  11. Have you ever had a test on your legs (blood pressure cuffs on your ankles),
    sometimes known as PVR?
  12. Have you ever had a venous sonogram (also called venous Doppler)?
    If yes, when?
  13. Do you have any of the following risk factors?

HOURS - MON - THUR: 7AM - 9PM, FRI: 7AM - 8PM, SAT: 8AM - 4PM, SUN: CLOSED

2025 RICHMOND AVENUE, STATEN ISLAND, NEW YORK 10314 PHONE: 718.477.1927 FAX: 347.630.9968

COPYRIGHT 2016 AMDS RADIOLOGY

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