Name

User Email

Phone Number:

1. Gender

2. Do you smoke or have a history of smoking?

3. Do you have any health conditions such as obesity, heart disease, or cancer?

4. Do you have a family history of varicose veins or vein disorders?

5. Have you ever had any leg injuries or surgeries in your lower extremities?

6. Do you have visible varicose veins or bulging veins?

7. Have you noticed any skin changes on your legs such as darkening, thickening, oozing or ulcers?

8. How would you describe your physical activity level at home or at work?

9. How often do you engage in activities that require prolonged standing or sitting?

10. Do you experience swelling or redness in your legs, especially towards the end of the day or after long periods of sitting or standing?

11. Do you experience leg pain or cramps, especially after standing for long periods?

12. Do you often feel a heaviness or throbbing sensation in your legs, especially after standing for long periods?

13. Are you currently pregnant or have had multiple pregnancies?

14. Do you have a history of deep vein thrombosis (DVT) or blood clots in your legs?

15. Do you use hormonal contraception or hormone replacement therapy?

Is there any additional information you'd like to share with us?