Do you experience any of the below symptoms of  venous disease?

  • Heaviness
  • Aching
  • Swelling
  • Throbbing
  • Itching
  • Pain
  • Burning
  • Cramping
  • Muscle fatigue

If you said yes to any of these, you may be one of the 80 million Americans suffering from venous disease.

Please fill out the following questionnaire to assist us in your vein disease diagnosis.

Name*

Email Address*

Phone Number*

Are your legs heavy, tight, tired, dull or achy?

 Yes No

Do you have swelling in the legs and/or ankles?

 Yes No

Do you have skin, just above the ankle, that is brownish-red or discolored? Does it feel leathery, hard, or itchy?

 Yes No

Have you ever had a thrombosis or blood clot in your legs?

 Yes No

Have you ever worn, or been advised to wear, compression stockings?

 Yes No

If yes, was it a deep vein thrombosis (DVT)?

 Yes No

Do you have bulging varicose veins and/or spider veins?

 Yes No

Have you ever had vein stripping or vein treatment?

 Yes No

If yes, please describe:

Do you know of anyone in your family that has bulging varicose veins?

 Yes No

Is there any other information you would like us to know?

*Required Field