1062 Forsyth St. Suite 1B Macon, Ga 31201
(478)-621-7501

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Vein Center

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Self Assessment

The following information will assist our clinicians in determining the cause of your leg pain or other symptoms. Please answer all of the questions and submit your answers to our clinicians for review. Someone from our office will contact you regarding your results.

Have you ever experienced any of the following signs and symptoms in your legs and ankles?

Leg pain, aching or cramping Leg or ankle swelling, especially at the end of the day Varicose veins, large painful "ropey" veins Open wounds or sores, such as above the inner ankle Small spider veins Burning or itching of the skin "Heavy" feelings in the legs Skin discoloration or texture changes Restless legs Pain in calves with walking or exercise, which is relieved by rest. Leg ulceration(s) around ankle Eczema, or dry itchy legs Open wounds on feet or legs which aren't healing

Do you stand for long periods of time, such as at work?

Yes No

Do you frequently engage in heavy lifting?

Yes No

When you walk or exercise, do you experience any aching or cramping or pain in the back of your legs?

Yes No

If you get pain with walking or excerise, does the pain subside with rest?

Yes No Not applicable

Have you ever been pregnant?

Yes No

Have you ever had varicose veins?

Yes No

Has anyone in your blood-related family ever had varicose veins or been diagnosed with chronic venous insufficiency or venous reflux?

Yes No

Do you have or have ever had painful sores or ulcers on your legs or feet that are not healing?

Yes No

Have you ever had any blocked arteries in your heart or neck?

Yes No

Have you had any treatments or procedures for vein problems?

Yes No

If you answered "yes" to one or more of the questions above, you may be a candidate for vascular screening and/or treatment. One of our clinicians will contact you promptly (typically within 24 hours) to schedule an appointment for you. Please complete the following questions to help us accommodate your schedule.

How would you prefer to be contacted?

Phone Email Mail

Full Name

Email

Phone

Best time to call?

Address

Address Line 2

City

State

Zip Code

Country

How did you hear about Central Georgia Vein Center?

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About Us

Our History- Cardiologists In Macon
Our Mission
Heart Hospital Affiliations
Notice of Privacy Practices
Cardiologists in Georgia

Our Services

Interventional Cardiology Services
Electrophysiology Services
Diagnostic Services
Remote Monitoring Services
Vein Specialists

Quick Contact

contact@centralgaheart.com
478-741-1208

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