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  • VASCULAR HISTORY: (please check all that apply)

    Do you have or have you ever been diagnosed with:
  • Do you experience any of the following in your legs?

  • Which of the following do you currently do to improve your leg vein symptoms

    Which of the following do you currently do to improve your leg vein symptoms

    Family History

    Has any member of your family (not to include spouse or in-laws) ever had the following conditions. If yes, indicate family member.
    Has any member of your family (not to include spouse or in-laws) ever had the following conditions. If yes, indicate family member

    VEIN TREATMENT HISTORY:

    Have you ever been treated for varicose veins with the following?
  • PERSONAL ACTIVITIES LIST:

    (please check all that apply)
    PERSONAL ACTIVITIES LIST: