Have you ever had spider veins or varicose veins? *

YesNo

Do you experience or suffer from any of the following signs or symptoms in your legs?

Leg Heaviness or FatigueRestless LegsItching or Burning of the SkinLeg or Ankle SwellingLeg Pain, Aching, Cramping or ThrobbingSkin Discoloration or Texture ChangeOpen Wounds, Sores or Venous UlcersLeg swelling in the morningPainful sores or ulcers on legs or feet that are not healingLeg pain while walkingNone of the above

Has anyone in your blood-related family ever had varicose veins or been diagnosed with venous disease?*

YesNo

Do you stand for prolonged periods of time? *

YesNo

Have you had any treatments or procedures for vein problems? *

YesNo

Have you ever had surgery to your veins in your legs, vein removal for open heart surgery, vein stripping in your legs, or cosmetic vein repair? *

YesNo

Have you ever had a test on your legs (blood pressure cuffs on your ankles) sometimes called a PVR?*

YesNo

Have you ever had a venous sonogram (also called venous Doppler)? *

YesNo

Have you ever had a venous ultrasound (also called venous Doppler)? *

YesNo

Do you have any risk factors listed below? *

High CholesterolCurrent SmokerPrevious SmokerHigh Blood PressureKidney ProblemsStrokeMini StrokeNone of the above

Do you have noticeable distended veins: *

ThighsCalfBehind kneeAnkleFootNone of the above

Do you have Diabetes? *

YesNo

Have you ever had a blood clot in your legs (DVT or Deep Vein Thrombosis): *

YesNo

Does your job or daily activity require standing for long periods of time: *

YesNo

Date of Birth