Self-assessmentThis self-assessment survey is intended to help better understand your symptoms and risk factors for venous disease. Once you submit a completed survey, a member of our staff will contact you within 1-2 business days to schedule a free consultation appointment.HistoryVaricose veins are large, bulging veins, as opposed to spider veins, which are thin veins just beneath the skin's surface. Have you ever had varicose veins?(Required) Yes NoSigns And SymptomsDo you experience or suffer from any of the following signs or symptoms in you legs?(Required) Restless Legs Varicose Veins Spider Veins Leg or Ankle Swelling Leg heaviness or fatigue Itching or Burning of the Skin Skin Discoloration or Texture Change Open Wounds, Sores or Venous Ulcers Leg Pain, Aching, Cramping or ThrobbingRisk FactorHave you had any treatments or procedures for vein problems?(Required) Yes NoDo you sit or stand for prolonged periods of time?(Required) Yes NoHas anyone in your blood-related family ever had varicose veins or been diagnosed with venous disease?(Required) Yes NoDo you exercise regularly?(Required) Yes NoDo you smoke?(Required) Yes NoHave you ever been pregnant?(Required) Yes NoLeg Photos (Optional)To help Vein & Vascular Center at Premier staff to better serve you, we are requesting that a photo of your legs be uploaded and submitted with your self-assessment survey. Please provide a full front photo and a full back photo of each leg (2 photos per leg) in natural light with your smart phone, tablet, or quality digital camera. Easily submit the photos using the upload tool.Max. file size: 2 GB.Please share your contact informationYour Full Name(Required)Phone(Required)Email(Required)How did you hear about us?Address Street Address Address Line 2 City State ZIP Code Method of Payment Insurance Self-pay
