You are now able to send photos safely to the Vein Clinic and get self-assessment from the comfort of your home.
Name*
Phone *
Email*
Address*
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City
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Safely and securely send photos to your doctor’s office so you can perform a self-assessment from the comfort and privacy of your home!
Leg pain itching and cramping
YesNo
Burning or itching of the skin
“Heavy” feeling in legs
Visible varicose or spider veins
Leg or ankle swelling, especially at the end of the day
Skin discoloration or texture changes, such as above the inner ankle
Open wounds or sores, such as above the inner ankle
Restless Leg Syndrome
Other (fill in the field below)
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Has anyone in your blood-related family 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?
507-322-6967