Answer what applies to you and skip the rest. Your answers add up to a score that shows how likely it is that pelvic veins are involved. This is a screening tool and does not diagnose.
Built by Joseph G. Magnant, MD, FACS, RPVI
4 short steps
Screening answers stay on this page
Does not diagnose
Screening questionnaireStep 1 of 4
Signs
Symptoms
History
Result
Call 911 for sudden leg swelling with chest pain or trouble breathing, or for severe belly pain that comes on suddenly.
What you can see
Check any that apply. For veins, swelling, or sores, choose the side.
Veins on the belly, groin, and buttock
Some of these can appear without any pelvic pain.
Legs and skin
How you feel
These often build after long periods of standing and later in the day.
Pelvis and lower belly
Pressure
Back, hip, and leg
About your symptoms
0 none10 worst
Past tests and treatment
Earlier procedures help us understand what has already been tried.
Vein procedures
Check each one you have had. Add the year if you know it.
Pelvic tests and procedures
After vein treatment
Who has evaluated you
Check every kind of doctor you have seen for these symptoms.
Records
Your next step
Prepare your details for clinic review.
Your screening results: included
Your included results transfer automatically into the secure Cognito Forms form, where you can edit them. Photos may upload as soon as you select them.
Opening the form doesn’t submit anything. In the form you add your name, contact details and photos, then review everything before you submit. What you enter there, and any photos you add, are handled by Cognito Forms.
Your screening answers stay on this page. A summary is shared only if you choose to continue to the form.
Two offices · Southwest Florida
Helping patients for over 20 years, close to home.
Built by Joseph G. Magnant, MD, FACS, RPVI
