Has your leg pain or symptoms last for 6 months or longer?
Use the drop down menu below to select an option.
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6 months or greater
Less than 6 months
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Are you 50 years of age or older?
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Yes - 50 years old or older
No - 1-49 years old
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Do you have leg pain or feet pain during exertion (ex. when walking, climbing stairs)?
Please select Yes or No using the drop down menu below
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Yes - I have pain during exertion
No - I don't have pain during exertion
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Do you have signs or symptoms of the following conditions?
Check all that apply and then click next button. If none applies hit next button.
Leg ulcers that will not heal
Tingling sensation in the legs or feet
Leg pain especially at night
Heavy legs
Legs or feet cold to the touch
Restless legs
Bluish legs
Use the checkbox for all that applies to your situation
Select all that applies and then click next button.
Smoking now or in the past
Diabetes
Family history of heart attack or cardiovascular disease
Family history of stroke
None of the above
Have you ever had surgery, balloon procedures or stents in your heart, kidneys, abdomen, legs or arms?
Please select one using the drop down menu.
Never had the above
Yes I had at least one of the above procedures
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We'd love to schedule a follow-up since you're experiencing discomfort in your legs. Fill out the fields below and a representative will contact you.
First Name
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Last Name
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Date of birth
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Email
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Phone
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