1 Contact Information 2 Patient Assessment Questions 3 Patient Risk Factors 4 Upload Photos 1. Contact InformationName* Email* Phone*Date of Birth* MM slash DD slash YYYY 2. Patient Assessment QuestionsLeg pain, aching or cramping Yes No Burning or itching of the skin Yes No “Heavy” feeling in legs Yes No Visible varicose or spider veins Yes No Leg or ankle swelling, especially at the end of the day Yes No Skin discoloration or texture changes, such as above the inner ankle Yes No Open wounds or sores, such as above the inner ankle Yes No Restless Leg Syndrome Yes No Other (fill in the field below)3. Patient Risk FactorsHas anyone in your blood-related family had varicose veins or been diagnosed with chronic venous insufficiency or venous reflux? Yes No Have you had any treatments or procedures for vein problems? Yes No Have you ever been pregnant? Yes No 4. Upload photosFile Drop files here or Select files Accepted file types: jpg, jpeg, gif, png, Max. file size: 10 MB, Max. files: 5. EmailThis field is for validation purposes and should be left unchanged.
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