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Online Vein Screening

Please describe your main concern with your vein circulation.*

Are you concerned about the appearance of your legs?*

Yes

Do you have bulging (varicose) veins?*

Yes

Which leg bothers you the most?*

Right

Left

Both are about the same

Vein problems are a circulation condition which causes inflammation in your body. Please check ALL symptoms that apply below:

Leg/Foot Symptoms *

Aching/tired legs

Foot/leg pain

Swelling in legs or feet

Tiny spider veins around the ankle, knee or thigh

Itching legs

Nerve or Muscle Symptoms *

Burning/stinging/cold feet

Leg cramps or Charlie Horses, especially at night

Numbness/tingling in legs or feet

Restless Legs

Cold feet

General Symptoms *

Decreased activity

Poor aleep

Reduced energy

Weight gain

Chronic fatigue/feeling run down

Other symptoms not listed above

If you checked any of the symptoms listed above, you likely have a vein condition.

Vein symptoms also have a specific pattern, as described below. Please answer each regarding your symptoms:

Are they worse after standing or sitting?*

Yes

Are they worse in the evening or night?*

Yes

Are they worse below the knees?*

Yes

Are they improved by rest overnight?*

Yes

Are they improved with leg elevation (recliner, sofa, etc)?*

Yes

Do you feel run down and tired, especially evenings?*

Yes

Please upload any photos of affected areas on your legs that would help us in the screening.

Leg Photo #1 (if needed)

Leg Photo #2 (if needed)

Leg photo #3 (if needed)

If you checked yes to any of the symptom patterns above, your chance of having a vein condition is even higher. Please complete the information below, and one of our staff will be in touch to set up a chat, video call or office visit.

Vein treatments are covered by most insurance.

First name*

Last name*

Email*

Phone number*

Date of birth

Preferred Method of Communication

Home Phone

Cell Phone

When is the best time for us to reach you?

Thank you. Please click "submit" below and one of our office clinicians will be in touch in a timely manner or, if your form is submitted after hours, on the next business day.