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MICC Vein Screening
Name
First
Last
Email
Phone
Check all symptoms that apply:
Varicose veins
Spider veins
Swollen legs
Aching legs
Other leg pain
What, if anything, temporarily improves your condition?
Elevation
Compression
Anti-inflammatories
Diuretics
Rest
Select any previous treatment you've had/tried:
None
Endovenous ablation
Sclerotherapy
Vein stripping
Cauterization or suturing of a bleeding vein
Wound care, skin graft or unna boot
Pain medications
Elevation
Compression
Anti-inflammatories
Please select the statement most fitting to you:
My legs feel good in the morning but progressively worse throughout the day
My legs are in constant pain and get worse throughout the day
My legs hurt most when active but feel better upon slowing down
My legs hurt most when sitting or inactive for long periods
My legs hurt most when standing still for long periods
My legs do not hurt
I do not like the appearance of my legs
Does anyone in your family have a history varicose veins, spider veins or swollen legs?
Yes
No
I'm not sure
Please upload a photo (if desired)
Max. file size: 2 GB.
Thank you!
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