Leg Health Self-Assessment

Venous Insufficiency Symptoms*

Heaviness in legs
Skin discoloration or skin changes
Spider veins
Tired legs
Itching
Varicose veins
Aching or throbbing pain
Slow healing wound
Family history of vein problems
Swollen legs and/or ankles
Restless legs
Sit or stand for long periods every day
Leg cramps
Burning sensation

If you checked one or more boxes and would like to be evaluated for venous insufficiency, please complete the information below and we will contact you to schedule this simple clinical screening exam, which is covered by most insurance.

First Name*

Last Name*

Phone*

Email*

Phone

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