* = Required Information
Right Left Both
Pain
Sharp
Dull
Aching
ltching
Burning
Cramps
Restless Legs at night
Leg pain caused by walking
Swelling
Leg Ulcers
Heaviness
Throbbing
Undesirable appearance
Leg pain caused by standing
Deep Vein Thrombosis blood clots in legs or lungs
Leg or ankle ulcers
Painful varicose veins
Clotting or blood problems
Sclerotherapy
To relieve symptoms have You:
Yes No
Yes No
Yes No
Diabetes
Heart disease
HIV positive or AIDS
Major injury or surgery to legs
Thyroid disease
Liver Disease
High blood pressure
Cancer
Yes No
Yes No
Yes No
Yes No