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Age
*
Approximately how many hours a day do you spend sitting?
*
Gender
*
Female
Male
Approximately how many hours a day do you spend standing?
*
Occupation
*
Have you ever been treated for a vein ailment?
*
Yes
No
Which signs do you have? (Choose as many as applicable.)
Varicose Veins
Varicose Veins Above Knee
Spider Veins Below Knee
Spider Veins Above Knee
Ankle Swelling
Leg Swelling
Skin Discoloration
Leg Wound
What symptoms do you have? (Choose as many as applicable.)
Heaviness
Restless Legs
Leg Cramps
Itching or Burning
Achiness/Pain
Night Time Urination
Other
None
Please upload any images related to your condition.
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Full Name
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First
Last
Email Address
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Phone Number
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