Questionnaire

Initial Patient Assessment
Completed when an individual first joins the Club.

The Purpose of this Questionnaire is to gather information about an individual when they first become a Member of the Club.
Please send us an Email if you have any comments to the Questionnaire.

Your answers will be a great value in the completion of our Research Project.

Please indicate each of your answers by checking the appropriate box.
Finally click on the 'Submit' button at the bottom of the Form.

SECTION A : Member's Medical History

Note that all values are set to default to 'No' so you only have to enter a value if it is 'Yes'.

A.1 Leg Ulcer Present ?	Yes	No
A.2 Leg Ulcers in the Past ?	Yes	No
A.3 DVT in the Past ?	Yes	No
A.4 Venous Surgery in the Past ?	Yes	No
A.5 Sclerotherapy in the Past ?	Yes	No
A.6 Diabetes Type 1 ?	Yes	No
A.7 Diabetes Type 2	Yes	No
A.8 Hypertension ?	Yes	No
A.9 Varicose Veins in the Past ?	Yes	No
A.10 Fixed Ankle Joint Right foot ?	Yes	No
A.11 Fixed Ankle Joint Left foot ?	Yes	No
A.12 Previous Smoker ?	Yes	No
A.13 Current Smoker ?	Yes	No

A.14 Type of Pain ?
A.15 Referred to a Professional ?

A.16 Height
A.17 Weight
A.18 Overall ABPI