Vein Screening Survey Take the first step to eliminating pain associated with vein disease. Our process is to review your submitted information and follow up with a brief consultation call. Have you ever had spider veins?Spider veins are typically known as the small surface, often-blue veins. Varicose veins are the larger, bulging, referred to as “ropey” veins, which are typically just beneath the skin’s surface. Have you ever had spider veins? YesNoHave you ever had varicose veins?Have you ever had varicose veins? YesNoSigns and SymptomsDo you experience or suffer from any of the following signs or symptoms in your legs? Leg Heaviness or Fatigue Restless Legs Itching or Burning of the Skin Leg or Ankle Swelling Leg Pain, Aching, Cramping or Throbbing Skin Discoloration or Texture Change Open Wounds, Sores or Venous Ulcers Risk FactorsHas anyone in your blood-related family ever had varicose veins or been diagnosed with venous disease?YesNoHave you been pregnant?Have you been pregnant? YesNoDo you sit or stand for prolonged periods of time?Do you sit or stand for prolonged periods of time? YesNoHave you had any treatments or procedures for vein problems?Have you had any treatments or procedures for vein problems?YesNoDo you exercise regularly?Do you exercise regularly? YesNoContact InformationYesFullName*Mobile*Email* Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Our process is to have one of our physicians or nurse review your submitted information and follow up with a brief consultation call.Would you like us to follow up with youSelect OneYesNoHow did you hear about us? Please indicate a day and time to follow up during our normal clinic hours of Monday - Friday (8:30am to 5:00pm)Select DaySelect DayMondayTuesdayWednesdayThursdayFridayBest time to reach you?Any timeMorning (8:30 am - 12 pm)Afternoon (12 pm -5 pm)LocationPhoneThis field is for validation purposes and should be left unchanged.