Venous Questionnaire (Villalta)

📋 Pre-consultation Questionnaire: Venous Disease

Deep venous insufficiency: venous recanalisation: Villalta score (post-thrombotic syndrome)

This questionnaire assesses the after-effects of a venous thrombosis (post-thrombotic syndrome) using the internationally used Villalta score. It helps our team prepare your consultation.

👤 Personal information

Full name *

Date of birth

Referring physician

Planned consultation date

Have you had a deep vein thrombosis (phlebitis)?

Yes No I don't know

If yes, approximate date and location

Current anticoagulant treatment?

Yes No

Which one?

📊 Villalta score: Post-thrombotic syndrome

Rate the symptoms in your most affected leg over the past month. For each item, tick the intensity (0=absent, 1=mild, 2=moderate, 3=severe).

Subjective symptoms:

Clinical signs:

📍 Location and symptoms

Most symptomatic limb

Left leg Right leg Both

Pain in the affected leg (VAS 0-10)

NoneMaximal

Do you have leg ulcers (wounds that do not heal)?

Yes No Healed

Tests performed (ultrasound, CT scan, MRI…)

💬 Additional information

Other current treatments or significant medical history

Questions for the doctor

📄 This questionnaire is meant to be completed at home, ahead of your consultation. Fill it in, then print it or save it as a PDF and bring it with you on the day of your appointment. Nothing is sent automatically. If you would like to send it in advance, you can email it yourself via Contact us (at your own responsibility).

For Pr Dohan · IR Cochin