Varicose Veins Self-Assessment Self Assessment How did you hear about veinscreening.com?*Select...Internet SearchCoxKTAR RadioPrintBillboardValPakEmail BlastHistoryVaricose 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?*YesNoSigns And SymptomsDo you experience or suffer from any of the following signs or symptoms in you legs? Restless Legs Spider Veins Varicose 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 Throbbing Risk FactorHas anyone in your family ever had varicose veins or been diagnosed with venous disease?YesNoHave you had any treatments or procedures for vein problems?YesNoDo you sit or stand for prolonged periods of time?YesNoDo you exercise regularly?YesNoDo you smoke?YesNoHave you ever been pregnant?YesNoOptional Patient Photo Upload Instructions: We are recommending that you submit a photo of your legs with your self-assessment. Please provide a full front and a back photo (1 each) in natural light with your smart phone, tablet, or quality digital camera, of your entire legs, and then upload the files to the form. Front of LegsBack of LegsPlease share your contact informationName* Phone*Email* City*State*Select...AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip Code*Method of PaymentInsuranceSelf PayIf you come in for a visit, how would you pay?NameThis field is for validation purposes and should be left unchanged.