Vein screening test

1
In your legs, do you ever have* This field is required.(please tick all that apply)
Aching or pain
Throbbing
Feeling of “heaviness”
Feeling of “tiredness”
Itching or burning
Restless leg
None of these
2
Do you have, or have been told that you have, thread veins on your legs?* This field is required.Choose the picture that best matches yours
A few thread veins
Thread veins in several places
Extensive thread veins
I don't have these
3
Do you have, or have been told that you have, varicose veins?* This field is required.Choose the picture that best matches yours
One and not very prominent
Several varicose veins
Extensive varicose veins
I don't have these
4
Do you have, or have been told that you have, ankle swelling?* This field is required.Choose the picture that is most similar to your legs
Slight swelling in one or both ankle(s)
More obvious swelling in one or both ankles
Severe swelling in one or both ankles
I don't have these
5
Do you have, or have been told that you have, a red marks on your legs?* This field is required.Choose the picture that is most similar to your legs
Small marks
Larger red marks extending up the leg
Extensive red marks of lower leg and skin changes
I don't have any
6
Do you have, or have been told, that you have a brown 'stain' on your legs?* This field is required.Choose the picture that is most similar to your legs
Light staining in the lower leg
Stronger staining on the lower leg
Dark and extensive staining on the lower leg
I don't have any
7
Please note, the next question contains photographs of leg ulcers which you may find challenging.

If you'd prefer not to see these, please stop the test and contact us on info@thewhiteleyclinic.co.uk to discuss your vein problems.
8
Do you have, or have you ever had, an ulcer on your lower legs - even if healed now?* This field is required.Choose the picture that is most similar to your legs
Healed leg ulcer
Open leg ulcer
Extensive ulceration
I don't have any
9
Do you have, or have you ever had, phlebitis - tender, hard lumpy veins on your legs?* This field is required.Choose the picture that is most similar to your legs
Small, single hard lumpy vein
Larger area, or several hard lumpy veins
Extensive hard, tender lumps with red or brown skin marks
I don't have any
10
Do you have any other signs that you think might be as a result of varicose veins, that we haven't shown pictures of?Please let us know what they are below
Huge
Large
Normal
Small
Ok
Ok
11
Have you ever had any of the following?* This field is required.Tick all those that apply
Stripping for Varicose veins
New surgery for Varicose Veins such as VNUS, EVL, ablation etc.
Injections (Sclerotherapy) for Thread veins
Injections (Foam or Liquid Sclerotherapy) for Varicose veins
Thrombophlebitis (also called phlebitis)
Deep Vein Thrombosis
Clot in your lungs (Pulmonary Embolism)
None of these
12
How do you manage your symptoms now?* This field is required.Tick all those that apply
I don't have any symptoms
Nothing
I put my feet up when possible
I wear compression / support stockings
I take medicine
Other
13
Can you walk unaided and without symptoms?* This field is required.
Yes
No
14
When you walk do you ever have to stop due to having any of the following?Please tick all that appy
Pain / ache in legs
Breathlessness
Chest pain
Being too tired
None of these
Other
15
Family history - tick if your mother or father ever had any of the following* This field is required.Tick as many as apply
Varicose veins
Leg ulcers
DVT (deep vein thrombosis)
None of these
16
Are you female?* This field is required.There are a couple of additional questions relating to varicose veins we'd like to ask if you are female
Yes
No
17
Do you have, or have you been told you have, varicose veins of the vulva, vagina, perineum, buttocks or upper thighs?They might look like these pictures - choose the one that most resembles yours
Bulging veins on the inside of your thigh
Bulging veins on the back of your legs
Bulging veins in your vaginal area (no image)
Don't have any
18
Are any of these statements true for you?Please tick all that apply
If you have been pregnant, you had varicose veins in your vulva or vagina
You get dragging or aching in your pelvis on standing
You get deep pain on sexual intercourse
You have an irritable bowel
You have an irritable bladder
None of these
19
Age* This field is required.Please let us know your age
20-29
30-39
40-49
50-59
60-69
70-79
80+
20
Name
First Name
Last Name
21
How did you hear about us?
GP/Consultant
Google
Adwords
Magazine/Newspaper
Social Media
Recommendation from Family/Friends
Radio
Other
22
Email address* This field is required.In order to get your results and recommendations, please let us have your email address. By entering your email address you are giving consent to The Whiteley Clinic sending your results and any recommendations to you by email. You may easily opt out at any time through the unsubscribe link in each email.
example@example.com
Confirm your email address
23
Would you like to consent to your email address being used by The Whiteley Clinic to keep you updated on treatment options that may be suitable for your condition, newsletters, events and other marketing related topics? Your consent to share personal information is entirely voluntary and you may withdraw your consent at any time. Should you have any questions about this process, or wish to withdraw your consent please contact: data.protection@thewhiteleyclinic.co.uk
YESNO
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Phone NumberIf you'd like us to call you about treatment options, please give us the best number to call you.
Area Code
Phone Number
25
Disclaimer

Please be aware that although this screening has been prepared by Prof Mark Whiteley, no screening can replace a full medical consultation and examination with a consultant vein surgeon.

The results from this screening are intended to be a guide only, not a full diagnosis.

If you have any concerns, you are encouraged to contact The Whiteley Clinic and book a full consultation and duplex ultrasound scan for a definitive diagnosis.

Contact info@thewhiteleyclinic.co.uk Tel: 0330 058 1850
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That's it - all done. Click on Submit to get your own personalised report
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Calculation
Should be Empty: