Vein Health Self Assessment

Do you experience any of the following symptoms in either or both legs - Pain, Swelling, Throbbing, Fatigue, Heaviness, Itching, Burning, Ulcers or Cramps?

Yes
No

Are your symptoms worse with long periods of standing or sitting?

Yes
No

Do you elevate you legs to relieve discomfort?

Yes
No

Do you have varicose or spider veins?

Yes
No

Do you suffer from restless legs or have you been diagnosed with Restless Leg Syndrome?

Yes
No

Are your symptoms worse at the end of the day?

Yes
No

Does pain in your legs sometimes make it difficult to sleep through the night?

Yes
No

Are you self-conscious regarding the appearance of your veins when they are not covered by clothing?

Yes
No

Have your symptoms (pain, swelling, discomfort), or the appearance of your legs, gotten progressively worse over time?

Yes
No

Name*

First Last

Email*

Phone