The following patient self assessment form will help our vein specialists to gain a better understanding of your symptoms and risk factors for developing vein disease. Once you complete and submit the form, one of our vein specialists will contact you shortly to schedule a follow-up with a CVR doctor.

Have you experienced any of the following symptoms?

Varicose Veins
Spider Veins
Swelling in the Legs or Ankles
Heavy or Fatigued Legs
Skin Discoloration or Texture Change
Burning or Itching Legs
Leg Cramping or Aching
Restless Legs
Sores or Open Wounds

Risk Factors

Have any of your family members ever had varicose veins or been diagnosed with venous disease?

Yes
No

Have you been previously treated for vein disease?

Yes
No

Do you stand or sit for long periods of time?

Yes
No

Are you physically active?

Yes
No

Do you smoke?

Yes
No

Are you, or have you ever been, pregnant?

Yes
No

Leg Photos (Optional)

Upload pictures of your legs:

Drop files here

Contact Information



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