Chronic Venous Insufficiency Screening Form

Chronic venous insufficiency (CVI) affects millions of people worldwide, causing leg pain, swelling, skin changes, and reduced quality of life. Early detection and proper assessment are crucial for effective treatment and preventing progression to more serious complications like venous ulcers.

This Chronic Venous Insufficiency Screening Form template provides healthcare providers, vascular clinics, and medical practices with a structured, professional tool for evaluating patients at risk for or experiencing symptoms of CVI. The form systematically captures patient demographics, medical history, specific venous symptoms, physical assessment findings, and helps determine the appropriate next steps—whether that's conservative management with compression therapy or referral for vascular surgery consultation.

Why Paperform for healthcare screening forms?

Paperform makes it simple to create professional, HIPAA-aware medical intake and screening forms that patients can complete before their appointment or during their visit. With conditional logic, you can tailor questions based on symptom severity, automatically calculate risk scores, and route high-priority cases for immediate follow-up.

Key benefits for healthcare practices:

• Professional, branded forms that match your clinic's look and feel, building patient trust from the first interaction
• Conditional logic that shows relevant follow-up questions based on symptom severity and patient responses
• Secure data collection with SOC 2 Type II compliance and data encryption, suitable for sensitive health information
• Seamless integration with your EHR system, Google Sheets, or CRM via Stepper, Zapier, or webhooks
• Automated workflows using Stepper to trigger appointment scheduling, send educational materials about compression therapy, or flag urgent cases for physician review
• Mobile-friendly design so patients can complete assessments on any device, in the waiting room or at home

The template includes comprehensive assessment sections covering the CEAP classification criteria, symptom severity scales, quality of life impact, and risk factors. Healthcare providers can customize the form to match their specific clinical protocols, add their practice branding, and integrate with existing patient management systems.

Whether you're a vascular surgeon, phlebologist, wound care specialist, or primary care provider, this template streamlines the CVI screening process, ensures consistent documentation, and helps identify patients who would benefit most from intervention—ultimately improving patient outcomes and practice efficiency.