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Please take a moment to complete the Venous Risk Assessment Form. A representative from The Vein Center will contact you regarding your results. |
The Vein Center at Taylor Regional Hospital
1700 Old Lebanon Rd. Campbellsville, KY 42718
Phone: 270.789.5844 |
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Patient Name: |
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Phone Number |
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Email Address |
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Do you suffer from?
Check Most Appropriate |
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Leg Pain |
None
Occasional
Daily
Limit Activities
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Swelling |
None
Evening/ankle
Afternoon/Leg
Morning/Leg
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Varicose Veins |
None
Limited
Moderate
Severe
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Spider Veins |
None
Only Limited
Moderate
Severe
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Skin Changes |
None
Limited
Moderate
Severe
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Neuropathy |
None
Limited
Moderate
Severe
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Restless Leg |
None
Limited
Moderate
Severe
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How would you rate your willingness to seek treatment to alleviate your symptoms? |
Very Interested
Somewhat Interested
Not Interested
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