Varicose Vein Screening Survey

ARE YOU A CANDIDATE FOR A VARICOSE VEIN SCREENING?

Please fill out this screening sheet and submt. Once we review your responses, we will contact you if you are a candidate for a consultation to discuss your options.

Form

Name*

Date of Birth*

Phone Number*

Email*

Have you ever had varicose veins?
YesNo

Please check any of the following symptoms you experience:
Leg pain, aching or crampingBurning or itching of the skinLeg or ankle swelling, especially at end of day“Heavy” feeling in legsLeg fatigueSkin discoloration or texture changesOpen wounds or soresRestless legs

Has anyone in your family ever had varicose veins or been diagnosed with chronic venous insufficiency or venous reflux?
YesNo

Have you had any treatments for vein problems?
YesNo

Do you stand for long periods of time?
YesNo

Do you frequently perform heavy lifting?
YesNo

Have you ever been pregnant?
YesNo

If you are a candidate, someone from our Windsong Vein team will get back to you.
How would you like us to contact you?
EmailPhone

If by phone, preferred time of day between 7 AM and 5 PM:

If you answered yes to 3 or more of the above, you are eligible for a consult to discuss vein disease and treatment options. Please allow 2-3 weeks for us to contact you. Please bring your co-pay to your scheduled consultation appointment. *** please note this is offered at our Spindrift location only***

Thank you for your Participation

CALL FOR AN APPOINTMENT ON OUR DIRECT LINE AT (716) 929-9484