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Taylor Regional Hospital

Venous Risk Assessment

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
* Patient Name:
* Phone Number
* Email Address
Do you suffer from?
Check Most Appropriate
* Leg Pain None
Occasional
Daily
Limit Activities
* Swelling None
Evening/ankle
Afternoon/Leg
Morning/Leg
* Varicose Veins None
Limited
Moderate
Severe
* Spider Veins None
Only Limited
Moderate
Severe
* Skin Changes None
Limited
Moderate
Severe
* Neuropathy None
Limited
Moderate
Severe
* Restless Leg None
Limited
Moderate
Severe
* How would you rate your willingness to seek treatment to alleviate your symptoms? Very Interested
Somewhat Interested
Not Interested