Vascular & Lymphatic Screening QuestionnaireFirst and Last Name*FirstLastPlease provide first and last name.Phone Number*Please include area code.Email address*Do you have diabetes?*YesNoDo you have heart disease?*YesNoHave you ever smoked?*YesNoDo you have high blood pressure or take medication for high blood pressure?*YesNoDo you have high cholesterol or take cholesterol medicine?*YesNoHave you ever had a stroke?*YesNoDo your feet get cold?*YesNoDo you notice hair changes or skin changes on your legs or feet?*YesNoDo your legs swell?*YesNoDo you experience any pain in your leg(s) or feet?*YesNoDo you have an infection, skin wound or ulcer on your feet or toes that are slow to heal (8-12 weeks)?*YesNoDo you have spider veins or varicose veins? YesNoDo your legs cramp while walking short distances? (Ex: Walking to your mailbox and back.)YesNoDo your legs bruise easily? YesNoDo you have excess fatty tissue in the legs that has been resistant to weight loss?YesNoHow did you hear about us?*SendThis field should be left blankOnce your form has been submitted a representative from our team will contact you during normal business hours Monday – Thursday 8:00AM-4:30PM, Friday 8:00AM-11:30AM. We look forward to speaking with you soon!