Free Vein Screening Application - Shinsegae Heart & Vascular Center

First Name*

Last Name*

City*

State*

Email Address*

Phone Number*

Desired Appointment Time*

Do you have bulging varicose veins? *

Do you have leg pain or swelling?*

Do you have burning or itching skin? *

Do you have heavy, tired, or restless legs? *

Do you have skin discolorations? *

Do you have ulcers on your legs? *

Have any family members had varicose veins or been treated for vein disorders? *

Have any family members had vein stripping? *

Do you sit or stand for long periods of time? *

Have you had multiple pregnancies? *

Do you consider yourself overweight? *

Do you smoke?*

Do you have congestive heart failure?*

Do you have liver disease? *

Do you have kidney failure? *

Have you had a previous vein stripping, ablation, or sclerotherapy? *