Varicose Vein Evaluation Form
Please complete this form to help us assess your varicose vein condition and recommend the best treatment options.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Do you have a family history of varicose veins?
Yes
No
Not sure
Please select the symptoms you are experiencing:
*
Visible bulging veins
Leg pain or aching
Swelling in legs or ankles
Itching or burning sensation
Leg heaviness or fatigue
Skin discoloration or ulcers
No symptoms
Other
How would you rate the severity of your symptoms?
*
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
Select any of the following risk factors that apply to you:
Pregnancy
Obesity
Prolonged standing
History of blood clots
Hormone therapy
None of the above
Other
Have you previously received treatment for varicose veins?
Yes
No
Please describe any previous treatments or relevant medical history.
Please upload a photo of your affected leg(s) if available.
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Submit Evaluation
Should be Empty: