VITALITY VEIN CARE

Virtual Vein Questionnaire

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Thank you for choosing to take an online screening with Virtual Vitality Vein Care. Please answer the questions below, take a picture of your area(s) of concern and submit this form. Once submitted, a vein specialist from VVC will contact you no later than the next business day.

Name*
Email*
Phone*
1. Do you have visible varicose veins or spider veins?*
2. Have you received any prior vein treatments?*
3. Do you have any of the following signs or symptoms?* (please check all that apply)*
- Leg Fatigue
- Leg Pain (caused by prolonged standing or sitting)
- Open Sores or Ulcers on Lower Legs/Ankles
- Tiredness in the Legs
- Itching of the Legs/Feet
- Swelling of the Ankles
- Leg Heaviness
- Tingling in the Legs/Feet
- Skin Discoloration in the Lower Legs
4. Is there a history of vein problems in your blood related family?*
5. Is there a history of blood clots in your blood related family?*
6. Upload Picture(s): Please upload pictures of your area(s) of concern.
Note: It IS possible to have vein disease without obvious, visible changes. If you do not have visible signs of vein disease submit your information without a picture.
Drop files here or
Accepted file types: jpg, png.
7. How did you hear about us?*
8. Are you a Texas Resident?*
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