Pelvic Varices / Pelvic Congestion Syndrome

  1. 1. Race*
    BlackAsianHispanicWhiteOther
  2. 5. How many children have you given birth to? *
    NoneOneTwo or more
  3. 6. In the past 6 months, have you experienced deep, dull, aching pain in your pelvis or lower abdomen?*
    YesNo
  4. 7. Does the pain worsen during your menstrual period?*
    YesNoPost-MenopausalNo pain
  5. 8. Does the pain worsen after sexual intercourse?*
    YesNoNo pain
  6. 9. Does the pain worsen after sitting or standing for an extended period of time?*
    YesNoNo pain
  7. 10. Have you been diagnosed with Polycystic Ovary Syndrome(PCOS)?*
    YesNo
  8. 11. Do you have a history of Varicose Veins in your family?*
    YesNo
  9. 12. Do you feel heaviness or fullness in your legs?*
    YesNo
  10. 13. Do you have a frequent urge to urinate?*
    YesNo
  11. 14. Do you often feel fatigued and lethargic?*
    YesNo

Book an appointment
Center is open from 8 AM - 5 PM on Mon - Fr
281-949-6020 office@coastalvascular.net
Same and next day appointments available!
Same and next day appointments available!