Preliminary Vein Screening Questionnaire

Preliminary Vein Screening Questionnaire


Preliminary Vein Screening Questionnaire

Have You Developed A Potentially Deadly Vein Disease?

By filling out and submitting the questionnaire below regarding your current medical condition and by uploading a picture of your leg veins, our staff will review your symptoms and may contact you to suggest scheduling a formal, in-office vein evaluation with one of our Riverview vascular surgeons.

Simply fill out the questionnaire below and click the “Send” button to submit your information to our office for further review.

    Your Name (required):

    Your Email (required):

    Your Phone Number (required):

    Your Age:



    Have you been experiencing any leg cramps or leg pain?


    Have you been experiencing any swelling in your legs or ankles?


    Have you been experiencing any feeling of heaviness in your legs?


    Do you have Restless Leg Syndrome (discomfort in legs while resting)?


    Have you been experiencing any numbness or tingling in your feet?


    Have you noticed any skin rash or skin discoloration on your legs or ankles?


    Have you developed any skin ulcers on your legs?


    Which of the following conditions apply to you?

    DiabetesHigh Blood PressureHigh CholesterolHeart DiseaseSmokerFamily History of Vein DiseaseNone

    Do you have spider veins?


    Do you have varicose veins?


    You may upload a photo of your leg or area of concern here:

    Is there any additional information you'd like to share with us?

    I Agree (required)
    I understand that this is a preliminary vein screening only for vein disease and does not constitute a complete or definitive diagnosis and does not include an in-office consultation. Information gathered in this screening is strictly confidential and is being collected for review and preliminary determination of the likelihood of vein disease existing in said participant. I hereby release the screening physician and all other health care providers from all responsibility in connection with this online screening process.

    Thank you for participating in The Vein and Vascular Institute of Riverview’s Preliminary Vein Screening!

    Once we review your information we may be contacting you to let you know if a vascular consultation with one of our vascular surgeons would be recommended for you.

    At our state-of-the-art vascular facilities, we treat all arterial and vein diseases. We specialize in non-invasive procedures to treat spider veins, varicose veins, venous leg ulcers, peripheral arterial disease, carotid artery disease and aortic aneurysms.

    Our technologically advanced vascular procedures allow our patients to have quick recovery times and enjoy very little to no scars at all.

    If you would like to consult with our Riverview vein specialists in person, please call (813) 999-3992 to schedule an appointment for an in-office consultation. Vein disease is progressive and only worsens with time, which can lead to blood clots, pulmonary embolism, stroke, and even death.


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