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? Yes No Do you have foot, calf, buttock, hip, or thigh discomfort (aching, fatigue, tingling, cramping, or pain) when you walk, which is relieved by rest? Yes No Are your toes or feet pale, discolored, or bluish? Yes No Do you have an infection, skin wound, or ulcer on your feet or toes that are slow to heal (8-12 weeks)? Yes No Do you have high cholesterol levels, or other blood lipid problems, or do you take medication to lower cholesterol? Yes No Do you have high blood pressure or take medication for high blood pressure? Yes No Do you have diabetes? Yes No Have you ever smoked? Yes No Have you previously had a stroke? Yes No Do you have heart disease? Yes No Name * First & Last Email * Phone * Primary care doctor * If you are human, leave this field blank. Submit Δ
