Vein & Vascular Questionnaire

Am I a candidate?

Fields marked with an * are required

Do you experience any pain at rest in your lower leg(s) or feet?
Do you have foot, calf, buttock, hip, or thigh discomfort (aching, fatigue, tingling, cramping, or pain) when you walk, which is relieved by rest?
Are your toes or feet pale, discolored, or bluish?
Do you have an infection, skin wound, or ulcer on your feet or toes that are slow to heal (8-12 weeks)?
Do you have high cholesterol levels, or other blood lipid problems, or do you take medication to lower cholesterol?
Do you have high blood pressure or take medication for high blood pressure?
Do you have diabetes?
Have you ever smoked?
Have you previously had a stroke?
Do you have heart disease?
First & Last

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Our Office Locations

cvam all locations


CVAM 6116 E Arbor Ave. #112 Mesa, AZ 85206
Fax: (480) 218-4353

CVAM 37100 N. Gantzel Rd #202 Queen Creek, AZ 85140
Fax: (480) 218-4353

CVAM 2730 S. Val Vista Dr.,Building 8N, #140 Gilbert, AZ 85295
Fax: (480) 218-4353

CVAM - Outpatient Service Center 4838 E Baseline Rd., Building 1 #108 Mesa, AZ 85206 
Fax: (480) 218-4353