Vein Screening Form | Vein Specialist Centers

Vein Screening Survey

Name *

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Last

Email *

Phone Number *

Since waking up today, how often have you had HEAVINESS in your leg to be treated?

Selected Value: 0

None of the time = 0
A little of the time = 1
Some of the time = 2
A good bit of the time = 3
Most of the time = 4
All of the time = 5

Since waking up today, how often have you had ACHINESS in your leg to be treated?

Selected Value: 0

None of the time = 0
A little of the time = 1
Some of the time = 2
A good bit of the time = 3
Most of the time = 4
All of the time = 5

Since waking up today, how often have you had SWELLING in your leg to be treated?

Selected Value: 0

None of the time = 0
A little of the time = 1
Some of the time = 2
A good bit of the time = 3
Most of the time = 4
All of the time = 5

Since waking up today, how often have you had THROBBING in your leg to be treated?

Selected Value: 0

None of the time = 0
A little of the time = 1
Some of the time = 2
A good bit of the time = 3
Most of the time = 4
All of the time = 5

Since waking up today, how often have you had ITCHING in your leg to be treated?

Selected Value: 0

None of the time = 0
A little of the time = 1
Some of the time = 2
A good bit of the time = 3
Most of the time = 4
All of the time = 5

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