Online Vein Screening Online Vein Screening Vein & Vascular Institute is able to provide patients with Online Vein Screenings. Please fill out the form below & if you desire you can upload photos of your legs. We will review during business hours and reach out to you regarding our suggestions. Personal InformationFull Name* Phone Number*Email* City or Town Zip Code Symptoms And Past Treatments: Do you experience any of the following? Varicose Veins - twisted veins that lie just under the skin which can result in protrusions. Spider Veins - blue or red veins in the skin Skin changes - discoloration or thickening Heavyness sensation of legs Aching Legs Swelling Tiredness, throbbing of legs Itching of skin in area of veins Leg Cramps Restless Legs Please describe the symptoms you are experiencingPlease describe the symptoms you are experiencingDoes any of the following improve your condition temporarily?Does any of the following improve your condition temporarily? Elevation Compression stockings Over the counter pain medication- Motrin, Advil, Alleve Tylenol Getting off your feet - sitting or laying down Activities like walking Have you had any of the following treatments?Have you had any of the following treatments? No previous treatments Elevation Compression Stockings Anti-inflammatories Prescription Pain medications Endovenous ablation (laser, EVLT or radio-frequency) Sclerotherapy Vein stripping or vein removal Treatment of a bleeding vein Wound care for leg skin breakdown or ulcer Which statement below best describes how your legs feel?Which statement below best describes how your legs feel?My legs feel good in the morning and become painful throughout the dayMy legs are always aching and get more fatigued as the day progressesMy legs hurt most when I am walking or active and feel better when I sit down or stop walkingMy legs hurt more when I am inactive or sitting for long periodsMy legs hurt or ache more when standing still for long periods of timeMy legs never bother meI do not like the appearance of my legsDoes anyone in your family have a history of venous disease (varicose veins, spider veins or swollen legs)?Does anyone in your family have a history of venous disease (varicose veins, spider veins or swollen legs)? Yes No How did you hear about us?How did you hear about us?Internet searchReferral from another patientNewspaperLinkedInFacebookPinterestTwitterYouTubeOther (Please Explain Below)FileUpload a photo(s) of your legs hereAccepted file types: jpg, gif, png, pdf, Max. file size: 50 MB.CAPTCHAEmailThis field is for validation purposes and should be left unchanged. Δ
