VEIN SCREENING FORM
I. Vascular History V. Vein Screening (to be completed by screening provider) Do you have or have you ever been diagnosed with: Varicose vein problems Y N Leg: R L Phlebitis (vein redness/tenderness) Y N Leg: R L Blood clots Y N Leg: R L Deep vein thrombosis (DVT) Y N Leg: R L Saphenous vein reflux Y N Leg: R L ................
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