.

Kyiv,
st. Andriya Verkhoglyada, 14A
(066) 313 33 00
(068) 313 33 00
Zaporizhia,
st. Dniprovska, 24
(066) 717 77 11
(068) 717 77 11
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CIVIQ-20 – Chronic Venous Insufficiency Questionnaire

Assessment of the quality of life of patients with chronic venous insufficiency (CIVIQ-20 – Chronic Venous Insufficiency Questionnaire).


Firstname



1. During the last 4 weeks, have you felt pain in the ankles and lower legs, if so, what intensity:

2. How much did your leg problems bother you in work or everyday life during the last 4 weeks:

3. During the past 4 weeks, was your sleep disturbed by leg problems and how often:

4. During the last 4 weeks, to what extent did problems with your legs bother you when performing actions - Standing for a long time? Indicate the degree of concern:

5. During the last 4 weeks, to what extent did problems with your legs bother you when performing actions - Climbing several flights of stairs? Indicate the degree of concern:

6. During the last 4 weeks, to what extent did problems with your legs bother you when performing actions - bending low, kneeling? Indicate the degree of concern:

7. During the last 4 weeks, to what extent did problems with your legs bother you when performing actions - Walking quickly? Indicate the degree of concern:

8. During the last 4 weeks, to what extent did problems with your legs bother you when performing actions - Driving in transport, cars, flying on airplanes? Indicate the degree of concern:

9. During the last 4 weeks, to what extent did problems with your legs bother you when performing activities - Doing housework (doing chores in the kitchen, holding a child, ironing, washing the floor, cleaning furniture, doing something with your own hands)? Indicate the degree of concern:

10. During the last 4 weeks, to what extent did leg problems bother you when performing activities - going for walks, weddings, parties, buffets:

11. During the last 4 weeks, to what extent did problems with your legs bother you when performing activities - Playing sports, doing physical exercises:

12. Leg problems can also affect your mood. To what extent have you felt during the last 4 weeks - I was (was) tense. Indicate the degree of concern:

13. Leg problems can also affect your mood. To what extent have you felt during the last 4 weeks - I got tired quickly (las). Indicate the degree of concern:

14. Leg problems can also affect your mood. To what extent have you felt during the last 4 weeks - I felt that I was burdening others. Indicate the degree of concern:

15. Leg problems can also affect your mood. How have you felt during the last 4 weeks - I always had to take precautions. Indicate the degree of concern:

16. Leg problems can also affect your mood. To what extent have you felt during the last 4 weeks - I was ashamed to show my legs. Indicate the degree of concern:

17. Leg problems can also affect your mood. To what extent have you felt during the last 4 weeks - I was easily irritated (las). Indicate the degree of concern:

18. Leg problems can also affect your mood. To what extent have you felt during the last 4 weeks - I felt (a) unable to work (oops). Indicate the degree of concern:

19. Leg problems can also affect your mood. How have you felt during the past 4 weeks - I had a hard time starting to move in the morning. Indicate the degree of concern:

20. Leg problems can also affect your mood. How have you felt during the last 4 weeks - I had no desire to go outside. Indicate the degree of concern:

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Kyiv, 01103,
st. Andrey Verhogliada 14A

(Pechersky district)

 

Work time:
Mon-Sun 9:00-19:00

(066) 313 33 00
(068) 313 33 00

Zaporizhia city,  69063
Dniprovska str., 24

(Olexandrivsky district)

 

Work time:
Mon-Sun 9:00-19:00

(066) 717 77 11
(068) 717 77 11

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