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Medical Questionnaire
To assist the doctor at Crown Medical. Please complete the following medical questionnaire. Our goal is to provide you with the best quality assessment. When complete click the submit button below.
First Name:
Last Name:
Phone:
Email:
Date of Birth:
1. How long have you had varicose had varicose veins?
2. Does any other family member have varicose vein?
Who?
3. Have you had treatment before?
4. Have you ever developed an ulcer on your legs?
When?
5. Have you ever had a thrombus in your legs?
When?
6. Does the pain in your varicose vein elevate during your menstrual cycle?
7. What type of symptoms do you have? example: Pain in legs, Cramps at night
Where?
8. Do you notice that your varicose veins are bulging popping out more
Explain:
9. Do you notice any color change in your skin, in or around the affected area
Explain
10. Do you notice that your feet get some inflammation at the end of the day?
How big is it?
11. Please describe any and all other symptoms and condition that you think are important for us to consider as part of you varicose veins evaluation?
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Verification & Submit
Crown Medical
The Experience you can trust.
