Self-Assessment This self-assessment survey is intended to help better understand your symptoms and risk factors for venous disease. Once you submit a completed survey, a member of our staff will contact you within 1-2 business days to schedule a free consultation appointment with a the core institute network physician.HistoryVaricose veins are large, bulging veins, as opposed to spider veins, which are thin veins just beneath the skin's surface. Have you ever had varicose veins?(Required) Yes No Signs And SymptomsDo you experience or suffer from any of the following signs or symptoms in you legs?(Required) Restless Legs Spider Veins Varicose Veins Leg or Ankle Swelling Leg Heaviness or Fatigue Itching or Burning of the Skin Skin Discoloration or Texture Change Open Wounds, Sores or Venous Ulcers Leg Pain, Aching, Cramping or Throbbing Risk FactorHas anyone in your blood-related family ever had varicose veins or been diagnosed with venous disease?(Required) Yes No Have you had any treatments or procedures for vein problems?(Required) Yes No Do you sit or stand for prolonged periods of time?(Required) Yes No Do you exercise regularly?(Required) Yes No Do you smoke?(Required) Yes No Have you ever been pregnant?(Required) Yes No Leg Photos (Optional)To help The CORE Institute’s Vein Health Center staff to better serve you, we are requesting that a photo of your legs be uploaded and submitted with your self-assessment survey. Please provide a full front photo and a full back photo of each leg (2 photos per leg) in natural light with your smart phone, tablet, or quality digital camera. Easily submit the photos using the upload tool. Drop files here or Select files Max. file size: 16 MB, Max. files: 4. Please share your contact informationYour Full Name(Required) Phone(Required)Email(Required) How Did You Hear About Us?Internet SearchNewspaperMagazineRadioTVEmailLocal Event/Health FairYellow PagesFacebookYelpValPakBillboardFriendFamily MemberAddress Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Method of Payment(Required) Insurance Self-Pay
