Name: Milford Vascular Institute
Price range: $

Take Our Vein Disease
Quiz To Find Out If You May Be Suffering From Venous Insufficiency

Vein disease is more common than you might think. In fact, between 35% and 40% of all Americans will suffer some form of chronic venous insufficiency, which makes it one of the most prevalent diseases in America.

You may be starting to feel the early signs of venous insufficiency, like leg heaviness or leg swelling and you may just think it’s because you’ve had a long day, or you’re tired.

By taking the venous insufficiency quiz below and submitting it to our staff, we may contact you to advise you to schedule an in-office vein evaluation. Early diagnosis and treatment of venous insufficiency can help prevent irreversible damage to your leg veins, and the development of potentially deadly blood clots.

Simply fill out the questionnaire below and click the “Send” button to submit your information to our office for further review, and it will be our pleasure to assist you.

Your Name (required):

Your Email (required):

Your Phone Number (required):

Your Age:

Gender:

FemaleMale

Do your legs ache after standing or sitting for extended periods of time?

NoOccasionallyDaily

Do your legs feel tired and heavy throughout the day?

NoOccasionallyDaily

Do you experience cramping or restless legs at night?

NoOccasionallyDaily

Do you have bulging veins or spider veins?

YesNo

Do your legs swell and become red?

NoOccasionallyDaily

Do you sit or stand for extended periods of time?

YesNo

Have you developed any skin ulcers on your legs?

YesNo

Have you had pregnancies?

YesNo

Have you ever sustained a leg injury?

YesNo

Do you have a family history of venous insufficiency?

YesNo

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

I Agree (required)
I understand that this quiz is simply for informational purposes and that I may be contacted by Milford Vascular Institute staff based on my responses. I understand that this is not a formal evaluation. Information gathered in this screening is strictly confidential and is being collected for review and preliminary determination of the likelihood of having vein disease. I hereby release the screening physician and all other health care providers from all responsibility in connection with this online quiz.

Thank you for participating in Milford Vascular Institute’s venous insufficiency quiz.

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

If you would like to go ahead and schedule a consultation with one of our vascular specialists, please call (203) 418-7386 and it will be our pleasure to care for you.

CALL (203) 418-7386