Varicose Vein Self-Assessment Survey

Full Name *

First

Last

Email *

Phone Number *

Zip Code *

Have you ever had varicose veins? *

Varicose veins are large, bulging veins, as opposed to spider veins, which are thin, branching veins just beneath the skin's surface.

Do you experience any of the following signs and symptoms in your leg and/or ankles?

Has anyone in your blood-related family ever had varicose veins or been diagnosed with chronic venous insufficiency or venous reflux? *

Have you had any treatments or procedures for vein problems? *

Do you stand for long periods of time, such as at work? *

Do you frequently engage in heavy lifting? *

Have you ever been pregnant? *

Additional Comments