1. Patient contact information Name*FirstLast Email* Phone*2. Patient assessment questions Chose one (or more) of the conditions that best describes your legs:Spider VeinsVaricose VeinsSwellingColor ChangesHealed UlcerActive UlcerDo you experience any of the following symptoms in your legs or ankles? Do you have Varicose Veins in the Legs? (veins that are enlarged or swollen & raised above the surface of the skin)YesNo Have you had a Deep Vein Thrombosis (DVT) in the past?YesNo Do your Legs feel Heavy, Tired, Achy or Restless?YesNo Do you experience swelling in your Legs or Ankles?YesNo Do you have an ulcer on the inside of your ankle?YesNo3. Patient Risk Factors Have you had any treatments or procedures for vein problems?YesNo If yes, what treatments did you have? Do you stand for long periods of time, such as at work?YesNo Do you frequently engage in heavy lifting?YesNo Are you Pregnant?YesNo Are there any previous or current Medical Conditions you feel we should know about?4. Upload photosIf possible, please upload a photo of your legs showing the vein problems. This will help our doctor provide more accurate feedback. Upload a Photo5. Contact What day would be best for us to call and review your vein screening information?MonTuesWedThursFri What time of day is best to call? (around 15-20 minutes needed)Morning Afternoon If would like to include your insurance information, it may help us process you more quickly. Insurance Name Insurance Phone ID # Group # Patient Date of Birth01020304050607080910111213141516171819202122232425262728293031Day / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberMonth / 2018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901YearSubmitReset
