Name*

E-mail Address*

Phone Number*

What your main concern?*

Do you experience:
---spider or unsightly purple veinsvaricose veinsswellingachinesspainheavinessleg crampsnight time urinationrestless legsnumbness or tingling in feetskin rash or discolored skinulceration or leg woundbleeding from your spider or varicose veinssuperficial clots in your varicose veins

Which of the following improve your symptoms or when are your symptoms improved?*
---elevationrestcompression hoseanalgesics/anti-inflammatoriesdiuretics or fluid pillswalkingat the beginning of the day

Which of the following worsen your symptoms?*
---sittingstandingworkingpregnancymenstrual cyclelying downwalkingat the end of the dayat the beginning of the day

Which of the following treatments have you had?*
---elevationcompression hoseanti-inflammatoriesanalgesics (pain medications)endovenous ablation (laser, EVLT or radiofrequency), closurefastinjection sclerotherapydiuretics (fluid pills)wound care, skin graft or ulna bootno previous treatment

Which statement most accurately describes how your legs feel?*
---legs are improved by the morning and gradually become more painfulachy and fatigued as the day progresseslegs hurt more when I walk and are relieved when I sit down or stop walking and pain returns when I walk about the same distance againlegs hurt or ache more when sitting or standing for long periods like on a car ride or plane ridelegs hurt or ache when standing stationary for long periods or time like in the kitchen or line at an amusement parkthey do not bother meI just do not like the way they look

Does anyone in your immediate or extended family have swollen legs, varicose veins or diffuse spider veins?*
---YesNo

If you like to upload photos, please so do here:



How did you arrive at the screening?*
---FacebookInternet AdvertisementInternet SearchLinkedInWebsiteOther (Please Explain Below)

If other source, please explain:

Accept Terms & Conditions To Proceed *
I hereby release the screening physician and all other health care volunteers from all responsibility in connection with this screening process. I understand that this is just a screening for venous disease and does not constitute a complete or definitive diagnosis. No one may use my screening results for any purpose except for inclusion in a statistical study, without reference to or publication of any personal identifying information including name, address, phone number and email. Information gathered in this screening is strictly confidential and is being collected for review and preliminary determination of the likelihood of venous insufficiency existing in said participant.