The following statements are about sensations you may have on one or both sides of your lower body. Please mark one box for each statement that best describes how your lower body felt on average in the past 4 weeks. If you have one of these sensations on both sides of your lower body, describe the side that seems to be affected the most.
Not at all	0
A little bit	1
Somewhat	2
Quite a bit	3
Very much	4
The skin on my leg feels tight	0 □ 1 □ 2 □ 3 □ 4 □
2.The skin above my ankle feels tight	0 □ 1 □ 2 □ 3 □ 4 □
3.My leg feels heavy	0 □ 1 □ 2 □ 3 □ 4 □
4.I have pain or discomfort in my leg	0 □ 1 □ 2 □ 3 □ 4 □
5.My leg is noticeably smaller when I get out of bed in the morning	0 □ 1 □ 2 □ 3 □ 4 □
6.I have swelling in my foot	0 □ 1 □ 2 □ 3 □ 4 □
7.I have swelling around my ankle	0 □ 1 □ 2 □ 3 □ 4 □
8.I have swelling in my lower leg (including knee)	0 □ 1 □ 2 □ 3 □ 4 □
9.I have swelling in my upper leg	0 □ 1 □ 2 □ 3 □ 4 □
10.I have swelling in my buttocks	0 □ 1 □ 2 □ 3 □ 4 □
11.I have swelling in my hip (on the side below the waist)	0 □ 1 □ 2 □ 3 □ 4 □
12.I have swelling below my stomach (below the belly button)	0 □ 1 □ 2 □ 3 □ 4 □
13.I have swelling in my genital area	0 □ 1 □ 2 □ 3 □ 4 □
Scores are summed, with a possible range of 0–52 points. Scores of 5 or more points indicate a positive screen.
© 2012 Mayo Foundation for Medical. Education and Research. All requests to use copies of this instrument should be addressed to Kathleen Yost, PhD (yost.kathleen@mayo.edu).