Vein Screening

Date of Birth :*

Gender:*

Male

Female

Local Zip Code:*

Do you have leg pain?*

NoneOccasionallyDailyLimits Activity

Do you have swelling of the ankle or leg?*

NoneBy MorningBy Afternoon By Evening

Do you have visible varicose veins?*

Yes
No

Have you had major surgery lasting over an hour in the last month?*

Yes
No

Are you pregnant or had a baby within the last month?*

Yes
No

In the past month, if you have felt pain in the legs, what was the intensity of this pain?*

No PainLight PainModerate PainStrong PainIntense Pain

Using the images below as a reference, please check the condition below that correspond
to the condition of your legs.*

No visible signs of venous disease

Spider veins, reticular veins, malleolar flare

Varicose veins

Swelling without skin changes

Chronic skin changes (pigmentation, eczema, thickened skin)

Chronic skin changes with healed ulceration

Chronic skin changes with active ulceration

Select your Vein:

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