Today's Date
Your Name
Phone number
E-mail address
Required
Age
Sex
Height
Weight
Race
Caucasian
African/American
Asian
Hispanic
Native American
Other
Name of your personal doctor or primary care physician?
1. Do you experience tired, heavy feeling legs?
Yes
No
2. Do you get leg pains from prolonged sitting or standing?
Yes
No
3. Do you develop swollen ankles by the end of the day?
Yes
No
4. Do you have large varicose veins (greater than ¼”)?
Yes
No
5. Do you suffer from tingling, numbness, burning or cramping in the legs or feet?
Yes
No
6. Do you have a family history of vein problems?
Yes
No
7. Do you have skin discoloration on your lower legs?
Yes
No
8. Do you have hard to heal ulcers or sores on your lower legs?
Yes
No
9. Do you have a family history of blood clots in the veins?
Yes
No
10. If female, have you had one or more children?
Yes
No
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